Surgical Antimicrobial Prophylaxis in Pediatric Patients Undergoing Plastic Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Abstract

For many years, it was clearly shown that surgical procedures might be associated with surgical site infection (SSI). Many scientific institutions prepared guidelines to use in surgery to reduce abuse and misuse of antibiotics. However, in the general guidelines for surgical antibiotic prophylaxis, plastic surgical procedures are not addressed or are only marginally discussed, and children were almost systematically excluded. The main aim of this Consensus document is to provide clinicians with recommendations on antimicrobial prophylaxis for pediatric patients undergoing plastic surgery. The following scenarios were considered: clean plastic surgery in elective procedures with an exclusive skin and subcutis involvement; clean-contaminated/contaminated plastic surgery in elective procedures with an exclusive skin and subcutis involvement; elective plastic surgery with use of local flaps; elective plastic surgery with the use of grafts; prolonged elective plastic surgery; acute burns; clean contused lacerated wounds without bone exposure; high-risk contused lacerated wounds or with bone exposure; contused lacerated wound involving the oral mucosa; plastic surgery following human bite; plastic surgery following animal bite; plastic surgery with tissue expander insertion. Our Consensus document shows that antimicrobial perioperative prophylaxis in pediatric patients undergoing plastic surgery is recommended in selected cases. While waiting the results of further pediatric studies, the application of uniform and shared protocols in these procedures will improve surgical practice, with a reduction in SSIs and consequent rationalization of resources and costs, as well as limiting the phenomenon of antimicrobial resistance.

Keywords: antibiotics; burn; pediatric infectious diseases; plastic surgery; surgical antibiotic prophylaxis; wound.

Figure 1

Summary guide to tetanus prophylaxis in routine wound management. ¹ A primary series consists of a minimum of 3 doses of tetanus- and diphtheria-containing vaccine (DTaP/DTP/Tdap/DT/Td), ² Age-appropriate vaccine: DTaP for infants and children 6 weeks up to 7 years of age; Tetanus–diphtheria (Td) toxoid for persons 7 through 9 years of age; Tdap for persons 11 through 18 years of age, ³ No vaccine or Tetanus Immune Globulin (TIG) is recommended for infants younger than 6 weeks of age with clean, minor wounds (no vaccine is licensed for infants younger than 6 weeks of age), ⁴ Tdap is preferred for persons 11 through 64 years of age if using Adacel or 10 years of age and older if using Boostrix who have never received Tdap. Td is preferred to tetanus toxoid (TT) for persons 7 through 9 years, 65 years and older, or who have received a Tdap previously. If TT is administered, adsorbed TT product is preferred to fluid TT. All DTaP/DTP/Tdap/DT/Td products contain adsorbed tetanus toxoid. ⁵ Give TIG 250 U IM for all ages. It can and should be given simultaneously with the tetanus-containing vaccine. ⁶ For infants younger than 6 weeks of age, TIG (without vaccine) is recommended for ‘’dirty” wounds (wounds other than clean, minor). ⁷ Persons who are HIV positive should receive TIG regardless of tetanus immunization history.