Perioperative Prophylaxis in Pediatric Solid Organ Transplantation: A Baseline Stewardship Audit Using Routine Electronic Data

BACKGROUND: Perioperative antibacterial prophylaxis in pediatric solid organ transplantation varies by center in regimen, add-on agents, and stop dates. We used institutional protocols as a unified reference standard to establish baseline stewardship measures and targets for future quality-improvement work. METHODS: We retrospectively evaluated 164 pediatric transplants from 2010 to 2021. Using anesthesia timing and medication-administration data, we assessed on-time dosing, regimen selection, MRSA- and VRE-directed add-on agents, double anaerobic coverage, Gram-negative broadening during the protocol window, and discontinuation at organ-specific stop targets. We also used transplant-day anchoring and protocol-defined windows to describe whether primary-admission broad-spectrum exposure represented protocol-linked prophylaxis or later exposure. The audit measured protocol concordance and exposure patterns, not the appropriateness of deviations. RESULTS: Prophylaxis was given on time in 95.7% of procedures. Overall, 87.2% received the recommended initial regimen, 7.3% the protocol-defined beta-lactam allergy regimen, and 4.3% another broad Gram-negative regimen. Only 61.0% stopped the main regimen by the intended cutoff; stop performance was best in kidney transplantation and poorest in intestinal and multivisceral transplantation. MRSA-directed add-ons clustered in intestinal and multivisceral procedures and often extended beyond the intended duration. A secondary descriptive analysis identified contiguous protocol-linked continuation beyond the intended window in 8.6% of primary-admission broad-spectrum days of therapy. CONCLUSIONS: Timing and initial regimen selection were strong. The main baseline process measure requiring prospective review was continuation of protocol-linked antibiotics beyond cutoffs in abdominal transplantation. This audit shows how routine electronic data can be used to create reproducible measures and organ-specific targets for future stewardship and quality-improvement studies.