Surgical antibiotic prophylaxis in pediatric urology: Are we following the AUA guidelines? A multi-center evaluation of compliance and impact on morbidity.

INTRODUCTION

The American Urological Association (AUA) provides guidance on surgical antibiotic prophylaxis (SAP) for urologic procedures. In the absence of pediatric-specific recommendations, these guidelines are often extrapolated to children. We evaluated national compliance with SAP components (administration, antibiotic choice, timing, and re-dosing) across pediatric urologic procedures and examined associations with postoperative outcomes.

METHODS

Using the ACS NSQIP-Pediatrics database (2021-2023), we analyzed five procedure categories: hypospadias/urethroplasty, endourologic stone procedures, renal/bladder surgery, cystoscopy, and inguinal/scrotal cases. Compliance was defined per best practice statement on urologic procedures and antimicrobial prophylaxis (2019). Outcomes included infectious complications, readmissions, and reoperations. Multivariable logistic regression adjusted for demographic, clinical, and procedural covariates.

RESULTS

Among 25,058 procedures in which SAP is indicated, complete compliance was 75.8% for hypospadias/urethroplasty, 79.6% for endourologic stone procedures, and 76.4% for renal/bladder surgery. Non-compliance was associated with increased wound dehiscence (2.1% vs 1.4%, p = 0.046) and urinary tract infections (1.3% vs 0.7%, p = 0.036) after hypospadias repair, higher superficial infections (1.2% vs 0.7%, p = 0.009) and readmissions (5.7% vs 4.9%, p = 0.047) after renal/bladder surgery, and lower readmissions (3.3% vs 2.6%, p = 0.011) and reoperations (0.9% vs 0.7%, p = 0.003) with SAP during cystoscopy. On multivariate logistic regression analysis, SAP use was not associated with reduced post-operative morbidity.

CONCLUSIONS

National compliance with SAP is generally high but variable across components and procedures. Given inconsistent associations with outcomes and recognized risks of unnecessary antibiotic exposure, pediatric-specific, evidence-based SAP recommendations and stewardship frameworks are warranted.