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Aims: Surgical antimicrobial prophylaxis (SAP) is an important measure to reduce post-operative infections. Guidelines exist, but their efficacy and performance in children is poorly understood compared with adults. To review adherence to SAP guidelines, this study assesses risk factors for non-adherence and rate of early post-surgical infections. Methods: A retrospective cohort study of paediatric surgical cases (0-<18 years) at a tertiary children's hospital was performed. Patient characteristics, surgical factors and antimicrobial details were evaluated against hospital guidelines for overall adherence and domains of: antimicrobial choice, dose, re-dosing, timing and duration. Multiple regression analysis was used to determine risk factors for non-adherence. Hospital records were reviewed for post-operative infections at 7 and 30 days. Results: Among 326 cases, overall guideline adherence was 39.6% but varied by domain and surgical subspecialty. Incorrect wound classification was associated with overall non-adherence on multivariate regression (odds ratio (OR): 2.59; P < 0.001). Incorrect antimicrobial choice was more likely in children with penicillin hypersensitivity (OR 138.34, P = 0.004) and incorrect dosing more likely in adolescent patients (OR 4.33; P = 0.004). Presence of invasive devices was associated with prolonged duration of antimicrobials (OR 2.92, P = 0.016). Only two post-operative infections were documented by 30 days, but data were insufficient to exclude mild infections managed in the community. Conclusions: SAP was suboptimal in children, with areas for improvement including better guidance on wound classification, allergy management and care for adolescent patients. Documented infections were rare, but mild infections were unable to be excluded due to limited postdischarge information.

Children in hospital are frequently prescribed intravenous antibiotics for longer than needed. Programmes to optimise timely intravenous-to-oral antibiotic switch may limit excessive in-hospital antibiotic use, minimise complications of intravenous therapy and allow children to go home faster. Here, we describe a quality improvement approach to implement a guideline, with team-based education, audit and feedback, for timely, safe switch from intravenous-to-oral antibiotics in hospitalised children. Eligibility for switch was based on evidence-based guidelines and supported by education and feedback. The project was conducted over 12 months in a tertiary paediatric hospital. Primary outcomes assessed were the proportion of eligible children admitted under paediatric and surgical teams switched within 24 hours, and switch timing prior to and after guideline launch. Secondary outcomes were hospital length of stay, recommencement of intravenous therapy or readmission. The percentage of children switched within 24 hours of eligibility significantly increased from 32/50 (64%) at baseline to 203/249 (82%) post-implementation (p=0.006). The median time to switch fell from 15 hours 42 min to 4 hours 20 min (p=0.0006). In addition, there was a 14-hour median reduction in hospital length of stay (p=0.008). Readmission to hospital and recommencement of intravenous therapy did not significantly change postimplementation. This education, audit and feedback approach improved timely intravenous-to-oral switch in children and also allowed for more timely discharge from hospital. The study demonstrates proof of concept for this implementation with a methodology that can be readily adapted to other paediatric inpatient settings.