Congenital Heart Surgeons' Society

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Antibiotic Prophylaxis In Children Undergoing Delayed Sternal Closure: Foundations For Standardization Of Practice
John T. Kennedy III, BA1, Olivia DiLeonardo, MLIS2, Jennifer S. Nelson, MD, MS2.
1University of Central Florida College of Medicine, Orlando, FL, USA, 2Nemours Children's Hospital, Orlando, FL, USA.

Objectives: This study systematically reviewed the evidence related to antibiotic prophylaxis for delayed sternal closure following congenital cardiac surgery. Methods: Using PRISMA guidelines, a systematic review (1990-2018) was conducted, including reports that specified drug classes and treatment duration. Patient characteristics and infection rates were collected from the individual studies and aggregated for further analysis. Results: An initial search yielded 155 articles; 59 remained after title and abstract screening, and 20 remained after full-text review. The 20 studies described 22 antibiotic regimens used in over 1,400 children undergoing delayed sternal closure. The majority of patients were neonates and infants. Eighteen regimens disclosed treatment duration. There were 16 unique drug combinations, 8 unique treatment durations, and no identical regimens. Cefazolin only (5/22, 23%) was the most commonly-cited regimen. Common multi-agent regimens included vancomycin/gentamycin (2/22, 9.1%) and cefazolin/vancomycin/gentamycin (2/22, 9.1%). Prophylaxis was most often discontinued at sternal closure (4/17, 24%) or upon drain removal (4/17, 24%). Aggregated data revealed an incidence of 7.8% (70/898) for surgical site infections, 6.3% (41/652) for mediastinitis, 23% (38/160) for bloodstream infection, and 28% (22/78) for “all? infections. When analyzed by drug-class used, infection rates ranged from 2.2 - 11% for surgical site infections, 0 - 5.9% for mediastinitis, 1.7 - 42% for bloodstream infections, and 24 - 37% for “all? infections. Conclusions: Prophylactic antibiotic use for delayed sternal closure is highly variable, and infections are common in this surgical population. This study provides a needed starting point for trial design and protocol standardization following delayed sternal closure.