Adverse events associated with surgical antibiotic prophylaxis for outpatient circumcisions at US children's hospitals

Katherine Chan, Benjamin Whittam, Elizabeth A S Moser, Mark P. Cain, William E. Bennett

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Introduction: Doctors often use surgical antibiotic prophylaxis (SAP) despite limited evidence to support its efficacy. We sought to determine the association between SAP in children undergoing circumcision and the rate of perioperative adverse events. Material and methods: We performed a retrospective study of males >30 days old and <18 years old who underwent circumcision from 2004 to 2014 using the Pediatric Health Information System database. We excluded inpatients and those with any concomitant procedures. We used chi-square or Fisher's exact test to determine the association between SAP and allergic reaction and any of the following within 30 days: penile reoperation, hospital visit, or surgical site infection (SSI). We performed mixed effects logistic regression controlling for age, race, insurance, and clustering of similar practice patterns by hospital. Results: 84,226 patients were included: median age 2.2 years; 61.0% public insurance, 39.6% white. 8944 (10.6%) received SAP. On bivariate analysis, there were no associations between SAP and SSI (0.1% vs. 0.2%, p = 0.5), penile reoperation (0.01% vs. 0.04%, p = 0.4), or hospital visit (5.5% vs. 5.5%, p = 0.8). Patients who received SAP were more likely to have a perioperative allergic reaction than those who did not (3.5% vs. 2.9%, p = 0.0004). On multivariate analysis, those who received SAP had 1.5 times the odds of an allergic reaction (OR 1.5, 95% CI 1.3-1.7; p < 0.0001) and a hospital visit (OR 1.2, 95% CI 1.1-1.3; p = 0.0021) compared with those who did not (Table). Discussion: SAP did not decrease the risk of penile reoperation or SSI. Use of SAP was associated with an increased risk of allergic reactions and hospital visits. Strengths of the study include its large sample size, which enabled detection of rare outcomes with adequate statistical power and the generalizability of our findings to many patients and other types of procedures. Limitations include the lack of outpatient data and the possibility that we could have overestimated the incidence of allergic reactions by including patients who received epinephrine for some other reason. Conclusions: We found no compelling evidence to support the use of SAP in children undergoing circumcision and it was associated with an increased risk of allergic reaction and hospital visits. This study highlights the need for specialty-specific guidelines for pediatric urologic procedures regarding the use of antibiotics for prophylaxis and for vigilant monitoring of practice variation.TableBivariate and multivariate mixed effects logistic regression examining the association between SAP and perioperative allergic reaction, penile reoperation, SSI, and ED visit or readmission.TableOutcomeSAP unadjusted OR (p-value)SAP adjusted OR (p-value)Perioperative allergic reaction1.2 (95% CI 1.2-1.6; p < 0.0001)1.5 (95% CI 1.3-1.7; p < 0.0001)Penile reoperation0.29 (95% CI 0.04-2.13; p = 0.2231)n/aSSI0.8 (95% CI 0.4-1.5; p = 0.4880)n/aED visit or readmission1.1 (95% CI 1.0-1.2; p = 0.0392)1.2 (95% CI 1.1-1.3; p = 0.0021)

Original languageEnglish (US)
JournalJournal of Pediatric Urology
DOIs
StateAccepted/In press - Jun 7 2016

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Antibiotic Prophylaxis
Outpatients
Hypersensitivity
Surgical Wound Infection
Reoperation
Insurance
Logistic Models
Pediatrics
Health Information Systems
Sample Size
Epinephrine
Cluster Analysis
Inpatients
Multivariate Analysis
Retrospective Studies

Keywords

  • Anti-bacterial agents
  • Circumcision
  • Drug-related side effects and adverse reactions
  • Perioperative care

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Urology

Cite this

Adverse events associated with surgical antibiotic prophylaxis for outpatient circumcisions at US children's hospitals. / Chan, Katherine; Whittam, Benjamin; Moser, Elizabeth A S; Cain, Mark P.; Bennett, William E.

In: Journal of Pediatric Urology, 07.06.2016.

Research output: Contribution to journalArticle

@article{f9590149234e4e269cbba1f93cb43975,
title = "Adverse events associated with surgical antibiotic prophylaxis for outpatient circumcisions at US children's hospitals",
abstract = "Introduction: Doctors often use surgical antibiotic prophylaxis (SAP) despite limited evidence to support its efficacy. We sought to determine the association between SAP in children undergoing circumcision and the rate of perioperative adverse events. Material and methods: We performed a retrospective study of males >30 days old and <18 years old who underwent circumcision from 2004 to 2014 using the Pediatric Health Information System database. We excluded inpatients and those with any concomitant procedures. We used chi-square or Fisher's exact test to determine the association between SAP and allergic reaction and any of the following within 30 days: penile reoperation, hospital visit, or surgical site infection (SSI). We performed mixed effects logistic regression controlling for age, race, insurance, and clustering of similar practice patterns by hospital. Results: 84,226 patients were included: median age 2.2 years; 61.0{\%} public insurance, 39.6{\%} white. 8944 (10.6{\%}) received SAP. On bivariate analysis, there were no associations between SAP and SSI (0.1{\%} vs. 0.2{\%}, p = 0.5), penile reoperation (0.01{\%} vs. 0.04{\%}, p = 0.4), or hospital visit (5.5{\%} vs. 5.5{\%}, p = 0.8). Patients who received SAP were more likely to have a perioperative allergic reaction than those who did not (3.5{\%} vs. 2.9{\%}, p = 0.0004). On multivariate analysis, those who received SAP had 1.5 times the odds of an allergic reaction (OR 1.5, 95{\%} CI 1.3-1.7; p < 0.0001) and a hospital visit (OR 1.2, 95{\%} CI 1.1-1.3; p = 0.0021) compared with those who did not (Table). Discussion: SAP did not decrease the risk of penile reoperation or SSI. Use of SAP was associated with an increased risk of allergic reactions and hospital visits. Strengths of the study include its large sample size, which enabled detection of rare outcomes with adequate statistical power and the generalizability of our findings to many patients and other types of procedures. Limitations include the lack of outpatient data and the possibility that we could have overestimated the incidence of allergic reactions by including patients who received epinephrine for some other reason. Conclusions: We found no compelling evidence to support the use of SAP in children undergoing circumcision and it was associated with an increased risk of allergic reaction and hospital visits. This study highlights the need for specialty-specific guidelines for pediatric urologic procedures regarding the use of antibiotics for prophylaxis and for vigilant monitoring of practice variation.TableBivariate and multivariate mixed effects logistic regression examining the association between SAP and perioperative allergic reaction, penile reoperation, SSI, and ED visit or readmission.TableOutcomeSAP unadjusted OR (p-value)SAP adjusted OR (p-value)Perioperative allergic reaction1.2 (95{\%} CI 1.2-1.6; p < 0.0001)1.5 (95{\%} CI 1.3-1.7; p < 0.0001)Penile reoperation0.29 (95{\%} CI 0.04-2.13; p = 0.2231)n/aSSI0.8 (95{\%} CI 0.4-1.5; p = 0.4880)n/aED visit or readmission1.1 (95{\%} CI 1.0-1.2; p = 0.0392)1.2 (95{\%} CI 1.1-1.3; p = 0.0021)",
keywords = "Anti-bacterial agents, Circumcision, Drug-related side effects and adverse reactions, Perioperative care",
author = "Katherine Chan and Benjamin Whittam and Moser, {Elizabeth A S} and Cain, {Mark P.} and Bennett, {William E.}",
year = "2016",
month = "6",
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language = "English (US)",
journal = "Journal of Pediatric Urology",
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T1 - Adverse events associated with surgical antibiotic prophylaxis for outpatient circumcisions at US children's hospitals

AU - Chan, Katherine

AU - Whittam, Benjamin

AU - Moser, Elizabeth A S

AU - Cain, Mark P.

AU - Bennett, William E.

PY - 2016/6/7

Y1 - 2016/6/7

N2 - Introduction: Doctors often use surgical antibiotic prophylaxis (SAP) despite limited evidence to support its efficacy. We sought to determine the association between SAP in children undergoing circumcision and the rate of perioperative adverse events. Material and methods: We performed a retrospective study of males >30 days old and <18 years old who underwent circumcision from 2004 to 2014 using the Pediatric Health Information System database. We excluded inpatients and those with any concomitant procedures. We used chi-square or Fisher's exact test to determine the association between SAP and allergic reaction and any of the following within 30 days: penile reoperation, hospital visit, or surgical site infection (SSI). We performed mixed effects logistic regression controlling for age, race, insurance, and clustering of similar practice patterns by hospital. Results: 84,226 patients were included: median age 2.2 years; 61.0% public insurance, 39.6% white. 8944 (10.6%) received SAP. On bivariate analysis, there were no associations between SAP and SSI (0.1% vs. 0.2%, p = 0.5), penile reoperation (0.01% vs. 0.04%, p = 0.4), or hospital visit (5.5% vs. 5.5%, p = 0.8). Patients who received SAP were more likely to have a perioperative allergic reaction than those who did not (3.5% vs. 2.9%, p = 0.0004). On multivariate analysis, those who received SAP had 1.5 times the odds of an allergic reaction (OR 1.5, 95% CI 1.3-1.7; p < 0.0001) and a hospital visit (OR 1.2, 95% CI 1.1-1.3; p = 0.0021) compared with those who did not (Table). Discussion: SAP did not decrease the risk of penile reoperation or SSI. Use of SAP was associated with an increased risk of allergic reactions and hospital visits. Strengths of the study include its large sample size, which enabled detection of rare outcomes with adequate statistical power and the generalizability of our findings to many patients and other types of procedures. Limitations include the lack of outpatient data and the possibility that we could have overestimated the incidence of allergic reactions by including patients who received epinephrine for some other reason. Conclusions: We found no compelling evidence to support the use of SAP in children undergoing circumcision and it was associated with an increased risk of allergic reaction and hospital visits. This study highlights the need for specialty-specific guidelines for pediatric urologic procedures regarding the use of antibiotics for prophylaxis and for vigilant monitoring of practice variation.TableBivariate and multivariate mixed effects logistic regression examining the association between SAP and perioperative allergic reaction, penile reoperation, SSI, and ED visit or readmission.TableOutcomeSAP unadjusted OR (p-value)SAP adjusted OR (p-value)Perioperative allergic reaction1.2 (95% CI 1.2-1.6; p < 0.0001)1.5 (95% CI 1.3-1.7; p < 0.0001)Penile reoperation0.29 (95% CI 0.04-2.13; p = 0.2231)n/aSSI0.8 (95% CI 0.4-1.5; p = 0.4880)n/aED visit or readmission1.1 (95% CI 1.0-1.2; p = 0.0392)1.2 (95% CI 1.1-1.3; p = 0.0021)

AB - Introduction: Doctors often use surgical antibiotic prophylaxis (SAP) despite limited evidence to support its efficacy. We sought to determine the association between SAP in children undergoing circumcision and the rate of perioperative adverse events. Material and methods: We performed a retrospective study of males >30 days old and <18 years old who underwent circumcision from 2004 to 2014 using the Pediatric Health Information System database. We excluded inpatients and those with any concomitant procedures. We used chi-square or Fisher's exact test to determine the association between SAP and allergic reaction and any of the following within 30 days: penile reoperation, hospital visit, or surgical site infection (SSI). We performed mixed effects logistic regression controlling for age, race, insurance, and clustering of similar practice patterns by hospital. Results: 84,226 patients were included: median age 2.2 years; 61.0% public insurance, 39.6% white. 8944 (10.6%) received SAP. On bivariate analysis, there were no associations between SAP and SSI (0.1% vs. 0.2%, p = 0.5), penile reoperation (0.01% vs. 0.04%, p = 0.4), or hospital visit (5.5% vs. 5.5%, p = 0.8). Patients who received SAP were more likely to have a perioperative allergic reaction than those who did not (3.5% vs. 2.9%, p = 0.0004). On multivariate analysis, those who received SAP had 1.5 times the odds of an allergic reaction (OR 1.5, 95% CI 1.3-1.7; p < 0.0001) and a hospital visit (OR 1.2, 95% CI 1.1-1.3; p = 0.0021) compared with those who did not (Table). Discussion: SAP did not decrease the risk of penile reoperation or SSI. Use of SAP was associated with an increased risk of allergic reactions and hospital visits. Strengths of the study include its large sample size, which enabled detection of rare outcomes with adequate statistical power and the generalizability of our findings to many patients and other types of procedures. Limitations include the lack of outpatient data and the possibility that we could have overestimated the incidence of allergic reactions by including patients who received epinephrine for some other reason. Conclusions: We found no compelling evidence to support the use of SAP in children undergoing circumcision and it was associated with an increased risk of allergic reaction and hospital visits. This study highlights the need for specialty-specific guidelines for pediatric urologic procedures regarding the use of antibiotics for prophylaxis and for vigilant monitoring of practice variation.TableBivariate and multivariate mixed effects logistic regression examining the association between SAP and perioperative allergic reaction, penile reoperation, SSI, and ED visit or readmission.TableOutcomeSAP unadjusted OR (p-value)SAP adjusted OR (p-value)Perioperative allergic reaction1.2 (95% CI 1.2-1.6; p < 0.0001)1.5 (95% CI 1.3-1.7; p < 0.0001)Penile reoperation0.29 (95% CI 0.04-2.13; p = 0.2231)n/aSSI0.8 (95% CI 0.4-1.5; p = 0.4880)n/aED visit or readmission1.1 (95% CI 1.0-1.2; p = 0.0392)1.2 (95% CI 1.1-1.3; p = 0.0021)

KW - Anti-bacterial agents

KW - Circumcision

KW - Drug-related side effects and adverse reactions

KW - Perioperative care

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