Background

The rate of surgical site infection (SSI) after appendectomy for complicated appendicitis (CA) was high at our children's hospital. We hypothesized that practice standardization, including obtaining intra-operative cultures of abdominal fluid in patients with CA, would improve outcomes and reduce healthcare utilization after appendectomy.

Methods

A quality improvement team designed and implemented a clinical practice guideline for CA that included obtaining intra-operative culture of purulent fluid, administering piperacillin/tazobactam for at least 72 h post-operatively, and transitioning to oral antibiotics based on intraoperative culture data. We compared outcomes before and after guideline implementation.

Results

From July 2018-October 2019, 63 children underwent appendectomy for CA compared to 41 children from January-December 2020. Compliance with our process measures are as follows: Intra-operative culture was obtained in 98% of patients post-implementation; 95% received at least 72 h of piperacillin-tazobactam; and culture results were checked on all patients. Culture results altered the choice of discharge antibiotics in 12 (29%) of patients. All-cause morbidity (SSI, emergency department visit, readmission to hospital, percutaneous drain, unplanned return to operating room) decreased significantly from 35% to 15% (p=0.02). Surgical site infections became less frequent, occurring on average every 27 days pre-implementation and every 60 days after care pathway implementation (p=0.03).

Conclusions

Utilization of a clinical practice guideline was associated with reduced morbidity after appendectomy for CA. Intra-operative fluid culture during appendectomy for CA appears to facilitate the selection of appropriate post-operative antibiotics and, thus, minimize SSIs and overall morbidity.

中文翻译：

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减少复杂性阑尾炎儿科患者的手术部位感染：抗生素管理原则和质量改进方法的应用

背景

我们儿童医院的复杂性阑尾炎（CA）阑尾切除术后手术部位感染（SSI）的发生率很高。我们假设实践标准化，包括获得 CA 患者的术中腹液培养，将改善阑尾切除术后的结果并降低医疗保健的利用率。

方法

质量改进团队设计并实施了 CA 临床实践指南，其中包括获得脓性液体的术中培养、术后至少 72 小时给予哌拉西林/他唑巴坦，以及根据术中培养数据过渡到口服抗生素。我们比较了指南实施前后的结果。

结果

从 2018 年 7 月至 2019 年 10 月，63 名儿童接受了 CA 阑尾切除术，而 2020 年 1 月至 12 月为 41 名儿童。遵守我们的流程措施如下： 98% 的患者在实施后获得了术中培养；95% 接受了至少 72 小时的哌拉西林-他唑巴坦；对所有患者进行培养结果检查。培养结果改变了 12 名 (29%) 患者的出院抗生素选择。全因发病率（SSI、急诊就诊、再入院、经皮引流、计划外返回手术室）从 35% 显着下降至 15%（p=0.02）。手术部位感染变得不那么频繁，在实施前平均每 27 天发生一次，在护理途径实施后每 60 天发生一次 (p=0.03)。

结论

临床实践指南的使用与 CA 阑尾切除术后的发病率降低有关。CA 阑尾切除术中的术中液体培养似乎有助于选择适当的术后抗生素，从而最大限度地减少 SSI 和总体发病率。