Antibiotic Prophylaxis for Open Chest Management After Pediatric Cardiac Surgery

Abstract

Objectives: Although open chest management optimizes hemodynamics after cardiac surgery, it increases postoperative infections and leads to increased mortality. Despite the importance of antibiotic prophylaxis during open chest management, no specific recommendations exist. We aimed to compare the occurrence rates of bloodstream infection and surgical site infection between the different prophylactic antibiotic regimens for open chest management after pediatric cardiac surgery. Design: Retrospective, single-center, observational study. Setting: PICU at a tertiary children’s hospital. Patients: Consecutive patients younger than or equal to 18 years old with open chest management after cardiac surgery followed by delayed sternal closure, between January 2012 and June 2018. Interventions: None. Measurements and Main Results: We compared the composite occurrence rate of postoperative bloodstream infection and surgical site infection within 30 days after cardiac surgery between three prophylactic antibiotic regimens: 1) cefazolin, 2) cefazolin + vancomycin, and 3) vancomycin + meropenem. In 63 pediatric cardiac surgeries with open chest management, 17 bloodstream infections, and 12 surgical site infections were identified postoperatively. The composite occurrence rates of bloodstream infection and surgical site infection were 10 of 15 (67%), 10 of 19 (53%), and nine of 29 (31%) in the cefazolin, cefazolin + vancomycin, and vancomycin + meropenem regimens, respectively (p = 0.07). After adjusting for age, open chest management duration, extracorporeal membrane oxygenation use, and nasal methicillin-resistant Staphylococcus aureus colonization in multivariable analysis, there was no significant difference between the cefazolin and the cefazolin + vancomycin regimens (p = 0.19), while the vancomycin + meropenem regimen had a lower occurrence rate of bloodstream infection and surgical site infection than the cefazolin regimen (odds ratio, 0.0885; 95% CI, 0.0176–0.446; p = 0.003). Conclusions: In this study, a lower occurrence rate of postoperative bloodstream infection and surgical site infection was observed among patients with broad-spectrum antibiotic regimen after pediatric cardiac surgery with open chest management. Further studies, ideally randomized controlled studies investigating the efficacy of broad-spectrum antibiotics and their complications, are warranted before routine implementation of broad-spectrum prophylactic antibiotic regimen.

A Systematic Review of Antibiotic Prophylaxis for Delayed Sternal Closure in Children

“…A total of 28 studies were therefore included in this study (Table 1). 3,4,[6][7][8][9]12,14,[17][18][19][20][21][22][23][24][26][27][28][29][30][31][32][33][34][35][36][37] The 28 studies described antibiotic prophylaxis in >3,084 patients (2 studies did not disclose the number of patients with DSC).…”

“…Although prior studies have occasionally compared different antibiotic regimens in analyses of DSC and infection rates, these reports are limited to single-center studies, and the rationale for the antibiotic selection in these studies has been poorly described. 21,42 A prospective, multicenter trial guided by the results herein would provide generalizable data that could serve as the foundation for a standardized protocol in this population.…”

“…Postoperative infections were defined by each author. Most studies 3,6 -9,17 -24 used the National Health Safety Network/Centers for Disease Control and Prevention (NHSN/CDC) guidelines, 25 and one study 26 referenced the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) definitions. 11 Studies using the NHSN/CDC definitions referenced the 1988 guidelines, 2008 guidelines, or did not specify which guidelines were used.…”

Surgical site infection prevention bundle for children submitted to cardiac surgery

“…Children submitted to cardiac surgery are more susceptible to various types of infections, including SSI, due to its systemic inflammatory response, a consequence of extracorporeal circulation, and present an immature immunological system, in addition to being exposed to multiple invasive procedures (thoracic tubes, central venous access, open thorax) (25) . Therefore, the need for antimicrobial prophylaxis for these patients in the post-operative period, for at least 48 hours after surgery, has the objective of reducing the risk of infection and its efficacy is firmly proven among this population (25)(26)(27) . Thus, due to being a well-established intervention as an adjuvant factor in infection prevention, including SSI, the antimicrobial coverage in the postoperative period was designed and approved to integrate the bundle.…”

Surgical site infection after delayed sternal closure in neonates with congenital heart disease: retrospective case-control study

“…Patients received prophylactic antibiotic therapy with cefazolin (60–80 mg/kg a day) [ 20 , 21 ], which was initiated during the induction of anesthesia and continued until 48 h following surgery. After discontinuation of this regimen, prophylactic antibiotic coverage for indwelling mediastinal and pleural chest tubes was initiated.…”