Cost-Effective Methods of Optimizing Antibiotic Stewardship in Pediatric Non-Complicated Appendicitis

Author(s):
Angela Kao; Trudy Marks; Sean Maloney; Tanushree Prasad; Brant Todd Heniford; Graham Cosper

Background:

Acute non-complicated appendicitis is the most common pediatric surgical diagnosis and has been identified as a high-impact target for antimicrobial stewardship interventions, given the wide variability in antibiotic regimens within and between centers. Unnecessary carbapenem use and inadvertent postoperative dosing contributes to increased antimicrobial resistance and inefficient resource utilization. After observing wide institutional variability, a quality improvement initiative was developed targeting standardization of antibiotics for non-complicated appendicitis.

Hypothesis:

We hypothesized that implementation would reduce unnecessary antimicrobial use and improve cost-efficiency of care.

Methods:

A clinical practice guideline (CPG) [preoperative single dose ceftriaxone and metronidazole for non-penicillin allergic] was developed for pediatric non-complicated appendicitis and implemented into the standard order set in June 2017. Perioperative data was collected prospectively during the study period (June 2016-August 2018). Patients treated pre- and post-CPG implementation were compared using univariate analysis, with statistical significance set at p<0.05.

Results:

A total of 167 patients, including 58 pre-CPG and 109 post-CPG, underwent laparoscopic appendectomy. There were no differences in mean age (11.7 vs. 11.0 years, p=0.45), leukocytosis (15.3 vs. 15.5, p=0.82), or time from diagnosis to OR (8.9 vs. 8.8hours, p=0.71) between cohorts. Compared to pre-CPG, post-CPG patients were more likely to receive the recommended antibiotics (13.8% vs. 90.8%, p<0.0001), with a significant reduction in carbapenem use (81.0% vs. 9.2%, p<0.0001). Post-CPG patients also received fewer postoperative antibiotic doses (25.9% vs. 9.2%, p=0.004) and had lower pharmacy costs per patient ($123.20 vs. $67.70, p<0.0001), leading to 50% reduction in total pharmaceutical costs ($2620 vs. $1296, p<0.0001). There were no differences in complications (1.7% vs. 2.8%, p=1.00) or readmissions (5.2% vs. 1.8%, p=0.38).

Conclusions:

Implementation of a recommended antibiotic regimen for pediatric non-complicated appendicitis significantly reduced excess antibiotic dosing and pharmacy costs, resulting in improved antimicrobial stewardship and resource utilization. Using standardized orders to minimize practice variation and increase provider compliance, this study demonstrates the cost-effective impact of antimicrobial stewardship efforts in pediatric surgical patient populations.