Evaluating Postoperative Antimicrobial Prophylaxis Practices: A Pediatric Surgery Quality Collaborative Effort.

INTRODUCTION

Inappropriate postoperative antibiotic exposure in children contributes to avoidable adverse events without reducing surgical site infections (SSI), yet postoperative surgical antimicrobial prophylaxis (SAP) use varies widely across children's hospitals and determinants of effective stewardship remain unclear. This study evaluated variation in prophylaxis use and outcomes, identified drivers of inappropriate use, and characterized strategies employed by high-performing institutions to promote antimicrobial stewardship.

METHODS

We conducted a mixed-methods project across 30 National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) hospitals participating in the Pediatric Surgery Quality Collaborative. Phase 1 analyzed NSQIP-Ped SAP Semiannual Reports to quantify variation in postoperative prophylaxis use (>24 hours), SSI rates, and identify outliers. Phase 2 surveyed surgical quality improvement (QI) leaders and Antimicrobial Stewardship Program representatives regarding data use, QI initiatives, and interdisciplinary collaboration. Phase 3 involved semi-structured interviews with high- and low-performing hospitals, guided by the Theoretical Domains Framework, to examine organizational, behavioral, and cultural determinants of stewardship performance and to identify barriers, facilitators, and effective practices.

RESULTS

Postoperative SAP use >24 hours varied 11.8-fold among hospitals (1.5-23.7%; case-mix-adjusted rate ratios: 0.32-3.78) with no correlation between prolonged prophylaxis and SSI rates (r = -0.086, p = 0.652). High- and low-performing hospitals reported similar perceived barriers. Determinants of success included supportive culture, standardized protocols, shared accountability, and multidisciplinary collaboration led by engaged QI champions.

CONCLUSION

Substantial variation in postoperative antibiotic use exists without SSI benefit. High-performing centers achieved expected SSI rates without prolonged prophylaxis, highlighting an opportunity for targeted knowledge-sharing to strengthen pediatric surgical antimicrobial stewardship.