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Multicenter Study
. 2025 Apr 1;179(4):447-454.
doi: 10.1001/jamapediatrics.2024.6391.

Antimicrobial Prophylaxis Use and Outcomes for Children Undergoing Cholecystectomy

Kerri A McKie  1 , Anoosha Moturu  2 , Dionne A Graham  3 , Melvin Coleman  2 , Reiping Huang  2 , Catherine Grant  4 , Jacqueline M Saito  5 , Bruce L Hall  2   6 , Robert A Cina  7 , Jason G Newland  8 , Clifford Ko  2 , Shawn J Rangel  1
Affiliations
Multicenter Study

Antimicrobial Prophylaxis Use and Outcomes for Children Undergoing Cholecystectomy

Kerri A McKie et al. JAMA Pediatr. .

Abstract

Importance: Consensus guidelines from the Infectious Disease Society of America recommend against antimicrobial prophylaxis in the operative management of uncomplicated cholelithiasis; however, these guidelines were derived entirely from the adult surgical population.

Objective: To compare surgical site infection (SSI) outcomes between children undergoing cholecystectomy who received prophylaxis and those who did not.

Design, setting, and participants: This was a cohort study using data from 141 hospitals participating in the National Surgical Quality Improvement Program-Pediatric. Patients younger than 18 years who underwent cholecystectomy for uncomplicated cholelithiasis from January 2021 to December 2022 were identified. Exclusion criteria included diagnoses of acute cholecystitis, pancreatitis, choledocholithiasis, hematologic disorders, and emergent procedures.

Exposure: Administration of prophylactic antibiotics before incision.

Main outcomes and measures: The main outcomes were 30-day postoperative SSI and readmission. Propensity score weighting on the likelihood of receiving prophylaxis was used to balance groups on case acuity, duration of surgery, hospital discharge diagnosis, and patient characteristics. The association between outcomes and the use of prophylaxis was estimated using logistic regression models, weighted by the inverse probability of treatment with a random effect by hospital to control for hospital-level clustering. A secondary analysis was performed exploring the association between broad-spectrum prophylaxis and outcomes.

Results: Of 2234 children who met criteria for inclusion (median age, 15.3 years; 19.7% male [399 of 2025]), 2025 (90.6%) received prophylaxis (utilization rates ranged from 0% to 100% among hospitals). Cefazolin was the most commonly used antibiotic (69.2% [1401 of 2025]), and 559 of 2025 patients (27.6%) received extended-spectrum prophylaxis (compared with cefazolin). In the propensity-weighted cohort, SSI rates were lower for children who received prophylaxis compared with those who did not (18.0 of 2016 [0.9%] vs 7.8 of 212 [3.7%]; adjusted odds ratio [AOR], 0.28; 95% CI, 0.11-0.70), and rates were similar between children receiving cefazolin and those receiving more extended-spectrum antibiotics in a secondary propensity-weighted analysis (13.9 of 1399 [1.0%] vs 2.9 of 558 [0.5%]; AOR, 0.54; 95% CI, 0.15-1.95).

Conclusions and relevance: The results of this study support prophylaxis use for children undergoing nonemergent cholecystectomy; however, use of extended-spectrum antibiotics was not associated with superior outcomes compared with cefazolin alone. Opportunities to optimize infection prevention or antimicrobial stewardship were identified in more than one-third of all children undergoing cholecystectomy.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Saito reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. Dr Hall reported receiving compensation for being the consulting director of the American College of Surgeons (ACS) during the conduct of the study and is paid consulting fees as consulting director of the ACS National Surgical Quality Improvement Program. Dr Newland reported receiving grants from the AHRQ outside the submitted work. No other disclosures were reported.

References

    1. American College of Surgeons National Surgical Quality Improvement Program - Pediatrics. Semiannual Report (NSQIP-P SAR). Dates of Surgery Jan 1, 2022 - Dec 31, 2022. American College of Surgeons; July 2023. Available for download on the ACS NSQIP Workstations for the 157 hospitals that participate in the program.
    1. Centers for Disease Control and Prevention (CDC). Antibiotic resistance threats in the US 2019. US Dept of Health and Human Services. December 2019. Accessed May 15, 2024. https://www.cdc.gov/antimicrobial-resistance/media/pdfs/2019-ar-threats-...
    1. Holmes AH, Moore LS, Sundsfjord A, et al. . Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176-187. doi:10.1016/S0140-6736(15)00473-0 - DOI - PubMed
    1. Colling KP, Besshoff KE, Forrester JD, Kendrick D, Mercier P, Huston JM. Surgical Infection Society guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease. Surg Infect (Larchmt). 2022;23(4):339-350. doi:10.1089/sur.2021.207 - DOI - PubMed
    1. American College of Surgeons National Surgical Quality Improvement Program - Pediatrics. Surgical Antimicrobial Prophylaxis Semiannual Report (NSQIP-P SAP SAR). Dates of Surgery Jan 1, 2021 - Dec 31, 2021. American College of Surgeons; July 2022. Available for download on the ACS NSQIP Workstations for the 157 hospitals that participate in the program.

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