Implementation of a Pediatric Surgical Stewardship Initiative Improves Perioperative Antibiotic Selection, Timing and Duration Without Worsening Clinical Outcomes

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Abstract Corresponding Author Sophie E. Katz, MD, MPH, Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University Medical Center, 2200 Children’s Way, Nashville, TN 37232, USA, (615) 343-6190. sophie.e.katz@vumc.org Funding No funding to report. Conflict(s) of Interest SK serves as a contractor for Merck and served as a consultant for Optum and received research support from Pfizer in the past year. All other authors have no conflict of interest or funding to disclose that is relevant to this research. Background Poor compliance with perioperative antibiotic prophylaxis recommendatikons is associated with increased risk of surgical site infection (SSI). Antimicrobial stewardship (AS) strategies are well established to improve antimicrobial use in the inpatient setting but not for surgical antibiotic prophylaxis. We describe implementation of surgical AS at a tertiary care children’s hospital and impact on perioperative antibiotic selection, timing and duration. Methods We conducted a quality improvement study of development and implementation of surgical AS. The baseline period was Nov 2017 – Oct 2019 and the implementation period was Nov 2019-Dec 2025. Prior to the baseline period, the surgical stewardship team (one AS clinician, an AS pharmacist, a surgical quality representative and a data analyst) began development of a Tableau dashboard to extract data from the electronic medical record in near real-time (EMR; Epic, Madison, WI) and track compliance by surgical service line with the following metrics for clean and clean-contaminated cases: preoperative timing, redosing, spectrum and post-operative duration of antibiotics (Table). Appropriate antibiotic was defined for each procedure type according to the National Surgical Quality Improvement Program (NSQIP) AS pilot. The dashboard captured specialty-specific and patient-level data to identify areas for improvement and increase buy-in from surgeons. Other strategies that were implemented sequentially included standardization of surgical prophylaxis recommendations (2021), dissemination of scorecards to surgical quality champions and division directors (2024), EMR interventions, and development and dissemination of educational materials (Figure). Results Compared to the baseline period, the implementation period had significant improvement in compliance with recommendations for preoperative timing (97.3 vs 98%, p<0.001), redosing (50.9 vs 93.3%, p<0.001), antibiotic spectrum (79.1 vs 89.8%, p<0.001) and postoperative duration (93.4 vs 96.8%, p<0.001); Figure). Compliance with each metric varied by surgical service line, with the greatest increase in redosing compliance for cardiac surgery (87.3 percent change, p<0.001; Table). There were no differences between the periods in readmission or SSI rates (Table). Conclusion Implementation of a bundled approach to surgical stewardship is feasible and safely improved judicious antibiotic use in several service lines.

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