Naval Medical Center San Diego, San Diego, California.
Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania3Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
JAMA Otolaryngol Head Neck Surg. 2015 May 1;141(5):410-6. doi: 10.1001/jamaoto.2015.95.
More than 500,000 children undergo tonsillectomy each year in the United States. Although prior studies suggest that most patients received perioperative antibiotics, practice varies across centers. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published a practice guideline recommending against perioperative antibiotic use for pediatric tonsillectomy. The impact of this recommendation has not been thoroughly examined.
To determine the impact of the AAO-HNS guideline on the use of perioperative antibiotics and patient outcomes for pediatric tonsillectomy.
DESIGN, SETTING, AND PARTICIPANTS: This was a quasi-experimental study including 9265 children who underwent routine tonsillectomy from January 2009 through August 2012 within a large pediatric health care network containing hospital-based and ambulatory surgical facilities. Data were collected from a shared electronic health record and validated through manual medical record review. We used an interrupted time series analysis with segmented logistic regression and a nonequivalent dependent variable (tympanoplasty) to assess acute changes and differences in trends over time relative to guideline publication.
Publication of the AAO-HNS clinical practice guideline.
The primary outcome was antibiotic administration on the day of surgery. Secondary outcomes included otolaryngology clinic encounters, emergency department encounters, hospital admissions, and surgical procedures for bleeding in the 30 days following tonsillectomy.
Of 9265 tonsillectomies during the study period, 5359 met inclusion criteria. Immediately after guideline publication, perioperative antibiotic use dropped by 86.5% (P < .001) and was sustained throughout the postintervention period. Rates of otolaryngology clinic encounters, emergency department encounters, and hospital admissions did not change significantly over time. There was a small but statistically significant increase in surgical procedures for bleeding following the intervention from 1.35% (95% CI, 0.57%-2.14%) to 3.48% (95% CI, 1.85%-5.10%).
AAO-HNS guideline publication decreased perioperative antibiotic use for pediatric tonsillectomy across a large pediatric health care network. Although there were no changes in otolaryngology clinic visits, emergency department visits, or admissions, we found a small but significant increase in surgery for bleeding following guideline publication. Additional studies are necessary to verify this unexpected association.
在美国，每年有超过 50 万名儿童接受扁桃体切除术。尽管先前的研究表明，大多数患者在围手术期接受了抗生素治疗，但实践在各个中心之间存在差异。2011 年，美国耳鼻喉科学-头颈外科学会（AAO-HNS）发布了一项实践指南，建议不要在小儿扁桃体切除术中使用围手术期抗生素。该建议的影响尚未得到彻底检查。
确定 AAO-HNS 指南对小儿扁桃体切除术围手术期抗生素使用和患者结局的影响。
设计、设置和参与者：这是一项准实验研究，包括 9265 名在 2009 年 1 月至 2012 年 8 月期间在一家大型儿科医疗保健网络内接受常规扁桃体切除术的儿童，该网络包含医院内和门诊手术设施。数据来自共享的电子健康记录，并通过手动病历审查进行验证。我们使用具有分段逻辑回归和非等效因变量（鼓室成形术）的中断时间序列分析来评估指南发布后急性变化和随时间变化的趋势差异。
AAO-HNS 临床实践指南的发布。
主要结果是手术当天的抗生素使用情况。次要结果包括扁桃体切除术后 30 天内的耳鼻喉科诊所就诊、急诊就诊、住院和出血手术。
在研究期间的 9265 例扁桃体切除术中，有 5359 例符合纳入标准。指南发布后，围手术期抗生素使用率立即下降了 86.5%（P < .001），并在整个干预后期间持续下降。随时间推移，耳鼻喉科诊所就诊、急诊就诊和住院率无显著变化。干预后，出血手术的比例略有但具有统计学意义的增加，从 1.35%（95%CI，0.57%-2.14%）增加到 3.48%（95%CI，1.85%-5.10%）。
AAO-HNS 指南发布减少了大型儿科医疗保健网络中儿童扁桃体切除术的围手术期抗生素使用。尽管耳鼻喉科就诊、急诊就诊或住院率没有变化，但我们发现指南发布后出血手术的比例略有但具有统计学意义的增加。需要进一步的研究来验证这种意外的关联。
