PEDIATRICS Vol. 116 No. 6 December 2005, pp. 1317-1322 (doi:10.1542/peds.2004-1969)
Electronic Surveillance System for Monitoring Surgical Antimicrobial Prophylaxis
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* Preventive Medicine and Biometrics
Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado
Department of Epidemiology, the Children’s Hospital, Denver, Colorado
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONAPPENDIX: ICD-9 (CLINICAL...REFERENCES |
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Objectives. Antimicrobial surgical prophylaxis comprises one third of all antibiotic use in pediatric hospitals and 80% of all antibiotic use in surgery. Previous studies reported that antimicrobial surgical prophylaxis is often inconsistent with recommended guidelines. An electronic surveillance system was developed to measure antimicrobial utilization and to identify opportunities to improve and monitor the administration of antibiotics for surgical prophylaxis.
Methods. A retrospective cohort study was conducted on patients with selected inpatient surgical procedures performed from May 1999 to April 2000 at 4 US children’s hospitals. International Classification of Diseases, Ninth Revision surgical procedure codes were divided into clean or unclean categories, and an electronic surveillance system was designed using antibiotic and microbiologic culture utilization data to measure appropriate antimicrobial use associated with the surgical procedure. A medical chart review was conducted to validate the electronic system.
Results. Ninety percent of cases were classified properly by the electronic surveillance system as confirmed by medical chart review. Surgical antibiotic prophylaxis was not in accordance with the American Academy of Pediatrics (AAP) guidelines for almost half of all procedures. Prolonged antimicrobial administration in clean surgical procedures was the most frequent deviation from guidelines. Statistical differences between the index hospital and the comparison hospitals reflect both over- and underutilization of surgical prophylaxis with significant opportunity to improve prophylaxis for all hospitals.
Conclusions. Antimicrobial surgical prophylaxis at the children’s hospitals studied is not always consistent with published AAP guidelines. This electronic surveillance system provides a rapid, reproducible, and validated tool to measure easily the efforts to improve adherence to AAP surgical prophylaxis guidelines.
Key Words: wound infection • prophylaxis • antimicrobial utilization • surveillance • surgery
Abbreviations: AAP, American Academy of Pediatrics • ESS, electronic surveillance system • ICD-9, International Classification of Diseases, Ninth Revision • PHIS, Pediatric Hospital Information System
Surgical site infections result in increased morbidity and mortality and may be preventable with adequate antimicrobial prophylaxis.1,2 The consequences of these infections include increased morbidity and increased patient care costs secondary to increased length of hospital stay, pharmacy costs for antibiotics, and additional diagnostic laboratory tests. Antibiotics are the most commonly prescribed drugs in the practice of pediatrics and are often classified by their use for treatment of documented infection, empiric therapy, and prophylaxis.3–5 Prophylaxis comprises up to 80% of all antibiotic use in surgical patients. When the benefits of preventing an infection outweigh the risk for adverse effects of the antibiotics, the American Academy of Pediatrics (AAP) guidelines state that a single antimicrobial dose that provides adequate tissue concentrations throughout the surgical procedure should be sufficient. Many published studies and guidelines additionally use 1 or 2 doses postoperatively but generally utilize antimicrobial surgical prophylaxis for <24 hours.6,7 Specific prophylaxis recommendations are based on the 4 types of surgical wound classification: clean wounds, clean-contaminated wounds, contaminated wounds, and dirty wounds. Unless there is insertion of a prosthetic device or the consequence of infection is extreme, AAP guidelines do not recommend antimicrobial prophylaxis for clean procedures. Antimicrobial administration for contaminated and dirty wounds is considered treatment rather than prophylaxis. Multiple studies demonstrate inconsistent adherence to guidelines for surgical prophylaxis, resulting in both over- and underutilization of antibiotics, despite the presence of published guidelines.8–14
We hypothesized that an electronic surveillance system to measure retrospectively antimicrobial utilization would provide a mechanism for continuous quality improvement and help identify opportunities to improve surgical prophylaxis. Best practices in surgical prophylaxis may ultimately decrease costs, decrease adverse events, and potentially mitigate the emergence of antimicrobial resistance by reducing and optimizing antibiotic use.15,16
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: ICD-9 (CLINICAL...REFERENCES |
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A retrospective cohort study of 1493 patients who underwent 1630 inpatient surgical procedures from May 1999 through April 2000 was initially conducted at The Children’s Hospital (Denver, CO). The study was approved by the Colorado Multiple Institutional Review Board. Patient and laboratory data from 2 hospital databases (Transition Systems Inc, Version, Alt 10, Boston, MA; and Meditech version 4.8, Boston, MA) were merged into an electronic surveillance system (ESS) in Microsoft Access 97 (Microsoft Corp, Redmond, WA). The ESS contained patient information, including International Classification of Diseases, Ninth Revision (ICD-9) procedure codes,17 administration and duration of antibiotics, surgical service, and microbiologic culture (blood or tissue) data.
Surgical prophylaxis was operationally defined as the administration of antibiotics within 24 hours of an initial, uncomplicated surgical procedure. Antibiotic use was not considered prophylaxis when contemporaneous cultures of blood or tissue were done at the time of the procedure, suggesting suspected infection. Because of the inability to account for exact times of surgical procedure and antibiotic administration, 1 calendar day’s difference between surgical procedure and last dose of antibiotics was accepted as 24 hours (1 day) of antimicrobial administration. Central catheter insertion, secondary procedures, and surgical procedures that occurred with an overall frequency of <7 were excluded from analysis (see the Appendix for list of included procedures).
With the use of the ESS, ICD-9 procedure codes were divided into clean (Fig 1) and unclean (Fig 2) wounds (clean-contaminated, contaminated, and dirty wounds) on the basis of AAP guidelines.6 Patients who did not receive antibiotics for a clean procedure were categorized as having received care consistent with the AAP guidelines. Patients who received antibiotics for clean procedures that posed the risk for a life-threatening event if an infection occurred, had the insertion of a prosthetic device, and received antibiotics for <1 day were considered concordant with the guidelines, with the remaining cases considered an opportunity for improvement.
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One day or less of antimicrobial prophylaxis for unclean surgical procedures was considered concordant with AAP guidelines. The use of antibiotics for >1 day was considered to be consistent with the guidelines when a blood or tissue culture was obtained on the day of surgery, indicating the possibility of an infection. Opportunity groups that were not concordant with guidelines consisted of patients who did not receive antibiotics for unclean procedures and patients with antimicrobial use >1 day without evidence of a blood or tissue culture taken. A blinded record review of a random sample of all patients was conducted to validate the conclusions of the ESS.
Three Pediatric Hospital Information System (PHIS) participating hospitals similar to the index hospital were defined as comparison hospitals, selected on the basis of total hospital beds, total inpatient surgical procedures for the year 2000, average length of stay, and total days of patient care. Approval for the use of comparator hospital data was given by PHIS after identifying information was removed. Comparison hospital patient data consisted of ICD-9 procedure codes, wound classification, administration and duration of antibiotics, and surgical service and culture (blood or tissue) data using electronic definitions already described. The index hospital then was compared with the 3 comparable pediatric hospitals to identify any differences and identify the range of antimicrobial prescribing practices that were discordant with published guidelines.
Statistical Analysis
Statistical analysis was performed using SAS statistical software, Version 8.1 (SAS Institute Inc, Cary, NC). Sample size of medical charts to validate the accuracy of the ESS categorization of patients into the appropriate utilization groups allowing for a 20% ß error (80% power) was determined with Statistic Population Survey Module (Epi Info 2000, Centers for Disease Control and Prevention, Division of Public Health Surveillance and Informatics, Atlanta, GA). Confirmation of correct identification of antimicrobial prophylaxis categorization was calculated between the medical chart review and the ESS for each opportunity group in which prophylaxis was discordant with guidelines.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: ICD-9 (CLINICAL...REFERENCES |
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Fifty-four percent of the 1493 patients who were at the index hospital and underwent inpatient surgical procedures were female, and 57% of the total population were white with a median age of 7 years (range: 0–21 years). Figures 1 and 2 show the classification of surgical procedures and antibiotic use for the index and comparison hospitals. For the index hospital, 61% of the 1630 inpatient surgical procedures were clean surgical procedures, and 39% were unclean surgical procedures. Ninety-six percent of the patients with clean surgical procedures received antibiotics. Eighty-four percent of these patients had insertion of a prosthetic device or were identified as having extreme consequences if an infection occurred with 42% of these patients who received antibiotics for
1 day. The remaining 58% of patients who received antimicrobial prophylaxis for clean procedures because of increased risk received antibiotics for >1 day without evidence of a blood or tissue culture, supporting concern for an existing infection. An additional 16% of patients who had clean surgical procedures received antibiotics without risk for extreme consequences if infection occurred or insertion of a prosthetic device.
Eight percent of the 638 patients at the index hospital who had unclean procedures did not receive antibiotics. Forty-one percent of the patients who received antibiotics for prophylaxis of unclean procedures received them for 1 day. Antibiotics were given for >1 day in 42% of unclean procedures, but there was evidence of a blood or tissue culture at the time of surgery, whereas 58% received antibiotics for >1 day without cultures obtained.
The accuracy of the ESS categorization of patients at the index hospital was validated by a blinded review of a random subsample of 201 medical charts from the 4 patient groups that did not receive prophylaxis in accordance with the guidelines. Ninety percent of the procedures that were classified by the ESS as opportunities for improvement at the index hospital were confirmed by medical chart review.
When the PHIS comparison hospitals each were compared with the index hospital, there were significant statistical differences between opportunity groups with both over- and underutilization of antimicrobial prophylaxis between groups. As shown in Table 1, deviation from the AAP guidelines for surgical prophylaxis occurred approximately half of the time at both the index hospital and the PHIS comparator hospitals: 46% and 42%, respectively. Overall, all hospitals had many opportunities for improvement.
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Four main groups for all hospitals (index hospital and comparison hospitals) were identified as discordant with surgical prophylaxis guidelines. Prophylaxis not indicated consisted of patients who received antibiotics for clean procedures when there was no insertion of a prosthetic device and there was not extreme consequence if infection ensued (Fig 1). At the index hospital, patients who underwent urologic procedures, specifically circumcision, composed 67% of this opportunity group. Comparison hospitals similarly had urologic procedures that composed 54% of this opportunity group, with circumcision as the principal procedure.
Excess duration of prophylaxis consisted of clean procedures when antibiotics were used for >1 day for procedures that posed extreme consequence if infected or involved the insertion of a prosthetic medical device (Fig 1). Orthopedic surgical procedures, specifically anterior dorsal spinal fusions, composed most of the opportunity group at the index hospital. At the comparison hospitals, cardiothoracic surgery was the primary surgical service accounting for surgical procedures with antibiotic use for >1 day.
Missed antibiotic prophylaxis consisted of patients who had unclean procedures and did not receive antibiotics as recommended (Fig 2). At the index hospital, 58% of this group consisted of patients who had general surgery procedures that were categorized as unclean procedures. Pylorotomy was the most common procedure when prophylaxis was not used. General surgery at the comparison hospitals also contributed the most to this third opportunity group, with pylorotomy the most frequent surgical procedure.
Extended antibiotic use without concomitant cultures for patients who had unclean procedures consisted of those who received antibiotics for >1 day and did not have a blood or tissue culture at the time of the surgical procedure (Fig 2). General surgery accounted for most of the opportunities at both the index hospital and the comparison hospitals. The most common procedure in this opportunity group at all hospitals was laparoscopic appendectomies.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: ICD-9 (CLINICAL...REFERENCES |
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Using existing hospital database systems, this ESS proved to be a rapid and valid method for estimating the utilization of antimicrobials for surgical prophylaxis. The electronic surveillance tool is a good screening tool to provide an approximation of antimicrobial prophylaxis practice. Ninety percent of the procedures that were classified by the ESS as opportunities for improvement at the index hospital were confirmed by medical chart review. Limitations of this method include potential misclassification of surgical procedure and missing or misclassified antimicrobial and microbiologic data. In addition, physicians may choose to institute antimicrobial surgical prophylaxis for reasons other than those that we were able to discern from the administrative secondary data set available, so there is the chance of incorrectly categorizing the procedures and the appropriateness of prophylaxis. Even so, given the large numbers of patients who can be accessed quickly using this analysis of commonly available electronic data, identified opportunities are likely to be real, and ongoing measurement can document improvement.
The implications of over- and underutilization of surgical antimicrobial prophylaxis should be considered. The costs for overutilization of surgical prophylaxis include unnecessary drug utilization and its attendant preventable adverse events and the potential for increased resistance of organisms that are exposed to environmental pressure with antimicrobials.1,15–21 Underutilization of surgical prophylaxis ultimately may increase the rate of surgical site infections and subsequent associated costs such as increased hospital lengths of stay, pharmacy costs for antibiotics, diagnostic laboratory tests, and increased wound care needs. As a surveillance tool, the ESS provides an opportunity to follow longitudinally the antimicrobial prescribing patterns for various surgical procedures and ultimately correlate them with patient outcomes.
Four categories (opportunities) for improved utilization of antimicrobials were identified by the ESS: utilization of antimicrobial prophylaxis in clean procedures when it may not have been needed, continuation of antibiotics in clean procedures for >24 hours, no prophylaxis given for unclean procedures, and administration of antibiotics for >24 hours in unclean procedures without documented microbiologic culture at the time of surgery. Continuation of antimicrobials used for surgical prophylaxis is commonplace among many surgical specialties that perform clean surgical procedures. Sixty-two percent of pediatric patients who undergo orthopedic surgery continue to receive antibiotics postoperatively for longer than 48 hours without documentation of infection.22 Despite numerous adult studies that indicate that 24 hours of antibiotic prophylaxis for cardiothoracic surgery is effective in preventing postoperative infections,23,24 a survey of US pediatric cardiothoracic surgery programs reported administration of prophylaxis for at least 2 days in 68% of the centers with no indication of any benefits associated with the longer duration of surgical prophylaxis.25
Underutilization of antimicrobials in unclean surgical procedures was less common. The literature, however, supports the AAP’s recommendations for surgical prophylaxis in these unclean procedures. In 1 study, there was 64% less morbidity in children who received perioperative antibiotics for otolaryngologic procedures compared with those who did not, as judged by the amount of time to resumption of normal diet and pain analog scores.12
Antibiotic prophylaxis was also overutilized with antimicrobials administered for >24 hours in patients with unclean procedures. The literature supports the AAP guidelines for 1 dose of antibiotics as sufficient for unclean procedures to prevent postoperative infections unless there is evidence of an infection. A meta-analysis estimated the efficacy of antibiotic prophylaxis in preventing wound infections in percutaneous endoscopic gastrostomy in adult patients.26 A single dose of a broad-spectrum antibiotic, given 
30 minutes before surgery, was effective in reducing the risk for peristomal wound infections by 73%.
Initial evaluation at the index hospital validated the use of an ESS by retrospectively measuring the utilization of antimicrobial surgical prophylaxis. An important quality measure of surgical care should be the assessment of appropriate antimicrobial prophylaxis in addition to development of surgical site infections. The index hospital both over- and underutilizes antimicrobial surgical prophylaxis in patterns very similar to the 3 comparison hospitals. Although the antimicrobial prophylaxis utilization patterns at the index hospital should be addressed through targeted educational sessions, perhaps the AAP guidelines should be reassessed as well. The AAP guidelines are based on data from adult studies, and pediatric surgeons may not believe that they are applicable directly to children. Recent studies in adults report administration of surgical antimicrobial prophylaxis consistent with published guidelines but also show prolonged administration of antibiotics in >50% of cases.27
The ESS that was developed in this study can be applied to other health care organization secondary data sets to provide prospective antibiotic utilization that can be compared with other health care institutions. This system will provide evidence-based information for clinicians to analyze similarities and differences between practices at comparable hospitals and to help them evaluate best practices. Ultimately, this electronic surveillance tool can be used as a mechanism for continuous quality improvement and help identify opportunities to improve surgical prophylaxis and ultimately decrease costs, decrease adverse events, and potentially mitigate the emergence of antimicrobial resistance by reducing and optimizing antibiotic use.
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APPENDIX: ICD-9 (CLINICAL MODIFICATION) CODES FOR SURGICAL PROCEDURES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: ICD-9 (CLINICAL...REFERENCES |
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022 Ventriculostomy
0118 Other diagnostic procedures on brain and cerebral meninges
0139 Other brain incision
0159 Other excision or destruction of lesion or tissue of brain
0206 Cranial osteoplasty
0242 Replacement of ventricular shunt
0243 Removal of ventricular shunt
283 Tonsillectomy and adenoidectomy
0309 Spinal cord exploration
0359 Spinal structure repair
375 Heart transplantation
390 Systemic to pulmonary artery shunt
433 Pylorotomy
537 Repair of diaphragmatic hernia, abdominal approach
640 Circumcision
2263 Ethmoidectomy
2309 Tooth extraction
2762 Cleft palate correction
3009 Other excision or destruction of lesion or tissue of larynx
3328 Open lung biopsy
3474 Pectus deformity
3521 Replacement of aortic valve with tissue graft
3553 Prosthetic repair of ventricular septal defect
3561 Repair of atrial septal defect with tissue graft
3572 Other and unspecified repair of ventricular septal defect
3581 Total repair of tetralogy of Fallot
3584 Total correction of transposition of great vessels
3592 Creation of conduit between right ventricle and pulmonary artery
3594 Creation of conduit between atrium and pulmonary artery
3596 Percutaneous valvuloplasty
3721 Right heart cardiac catheterization
3725 Cardiac biopsy
3834 Resection of vessel with anastomosis
3885 Occlusion thoracic vessels
3921 Caval-caval-pulmonary artery anastomosis
4319 Gastrostomy
4466 Other procedures for creation of esophagogastric sphincteric competence
4469 Gastric repair
4610 Colostomy
4652 Large bowel stoma closure
4701 Laparoscopic appendectomy
4709 Other appendectomy
4791 Appendicostomy
4841 Soave submucosal resection of rectum
4841 Small bowel stoma closure
5123 Laparoscopic cholecystectomy
5137 Hepatic duct repair
5459 Lysis of peritoneal adhesions
5569 Kidney transplant
5587 Correction of ureteropelvic junction
5674 Ureteroneocystostomy
5787 Urinary bladder reconstruction
7735 Other division of bone
7869 Removal of implantable device site
7916 Closed reduction of fracture with internal fixation
7985 Open reduction dislocation hip
8047 Division of joint capsule, ligament, or cartilage
8104 Anterior dorsal fusion
8105 Posterior dorsal fusion
8109 Refusion of spine
8375 Tendon transfer or transplantation
8385 Ankle structure division
8604 Other incision with drainage of skin and subcutaneous tissue
8605 Incision with removal of foreign body from skin and subcutaneous incision
8607 Insertion of totally implantable vascular access device
8609 Skin/subcutaneous incision and device insertion
866 Free skin graft
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FOOTNOTES |
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Accepted Mar 1, 2005.
Address correspondence to Ann-Christine Nyquist, MD, MSPH, the Children’s Hospital, 1056 E 19th Ave B-276, Denver, CO 80218. E-mail: nyquist.ann-christine{at}tchden.org
No conflict of interest declared.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONAPPENDIX: ICD-9 (CLINICAL...REFERENCES |
|---|
- Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR; The Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of surgical site infection, 1999. Am J Infect Control. 1999;27 :97 –132[CrossRef][Web of Science][Medline]
- Haley RW, Schaberg DR, Crossley KB, et al. Extra charges and prolongation of stay attributable to nosocomial infections: a prospective interhospital comparison. Am J Med. 1981;70 :51 –58[CrossRef][Web of Science][Medline]
- Kesler R, Guhlow L, Saulsbury FT. Prophylactic antibiotics in pediatric surgery.
Pediatrics. 1982;69
:1
–3
[Abstract/Free Full Text] - Wenzel RP. Preoperative antibiotic prophylaxis. N Engl J Med. 1992;326 :337 –382[Web of Science][Medline]
- Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38 :1706 –1715[CrossRef][Web of Science][Medline]
- American Academy of Pediatrics. Antimicrobial prophylaxis. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:774–780
- Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther. 2001;43 :92 –97[Web of Science][Medline]
- Shapiro M. Perioperative prophylactic use of antibiotics in surgery: principles and practice. Infect Control. 1982;3 :38 –40[Web of Science][Medline]
- van Kasteren MEE, Kullberg BJ, de Boer AS, Mintjes-de Groot J, Gyssens IC. Adherence to local hospital guidelines for surgical antimicrobial prophylaxis: a multicentre audit in Dutch hospitals.
J Antimicrob Chem. 2003;51
:1389
–1396
[Abstract/Free Full Text] - van Houten MA, Luinge K, Laseur M, Kimpen JL. Antibiotic utilisation for hospitalised paediatric patients. Int J Antimicrob Agents. 1998;10 :161 –164[CrossRef][Web of Science][Medline]
- Shah SS, Sinkowitz-Cochran RL, Keyserling HL, Jarvis WR. Vancomycin use in pediatric neurosurgery patients. Pediatr Infect Dis J. 1999;18 :558 –560[CrossRef][Web of Science][Medline]
- Colreavy MP, Nanan D, Benamer M, et al. Antibiotic prophylaxis post-tonsillectomy: is it of benefit? Int J Pediatr Otorhinolaryngol. 1999;50 :15 –22[CrossRef][Web of Science][Medline]
- Hell K. Antibiotic prophylaxis in appendectomy. Often neglected—but necessary. Am J Surg. 1997;174 :422 –424[CrossRef][Web of Science][Medline]
- Dellinger E, Gross P, Barret TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 1994;18 :422 –427[Web of Science][Medline]
- Harbath S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance.
Circulation. 2000;101
:2916
–2921
[Abstract/Free Full Text] - Hecker MT, Aron DC, Patel NP, Lehmann MK, Donskey CJ. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with emphasis on the antianaerobic spectrum of activity.
Arch Intern Med. 2003;163
:972
–978
[Abstract/Free Full Text] - Schmidt K, Aaron WS. St. Anthony’s Softbound ICD-9-CM Code Book. Vols 1, 2, and 3. Reston, VA: St Anthony Publishing, Inc; 1997
- Evans R, Pestotnik S, Classen DC, et al. A computer-assisted management program for antibiotics and other antiinfective agents.
N Engl J Med. 1998;338
:232
–238
[Abstract/Free Full Text] - Saez-Llorens X, Castrejon de Wong MM, Castano E, et al. Impact of an antibiotic restriction policy on hospital expenditures and bacterial susceptibilities: a lesson from a pediatric institution in a developing country. Pediatr Infect Dis J. 2000;19 :200 –206[CrossRef][Web of Science][Medline]
- Hoelzer DJ, Zabel DD, Zern JT. Determining duration of antibiotic use in children with complicated appendicitis. Pediatr Infect Dis J. 1999;18 :979 –982[CrossRef][Web of Science][Medline]
- Bamberger DM, Dahl SL. Impact of voluntary vs enforced compliance of third-generation cephalosporin use in a teaching hospital.
Arch Intern Med. 1992;152
:554
–557
[Abstract/Free Full Text] - Nahata MC, Winters CB, Powell DA. Variation in prophylactic antibiotic use in pediatric orthopedic surgery. Drug Intell Clin Pharm. 1985;19 :834 –836[Abstract]
- LoCicero J. Prophylactic antibiotic usage in cardiothoracic surgery.
Chest. 1990;98
:719
–723
[Free Full Text] - Niederhauser U, Vogt M, Vogt P, et al. Cardiac surgery in a high-risk group of patients: is prolonged postoperative antibiotic prophylaxis effective?
J Thorac Cardiovasc Surg. 1997;114
:162
–168
[Abstract/Free Full Text] - Lee KR, Ring JC, Leggiadro RJ. Prophylactic antibiotic use in pediatric cardiovascular surgery: a survey of current practice. Pediatr Infect Dis J. 1995;14 :267 –269[Web of Science][Medline]
- Sharma VK, Howden CW. Meta-analysis of randomized, controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol. 2000;95 :3133 –3136[CrossRef][Web of Science][Medline]
- Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project.
Arch Surg. 2005;140
:174
–182
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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