Use of mechanical bowel preparation and oral antibiotics for elective colorectal procedures in children: Is current practice evidence-based? Elliot C. Pennington a , Christina Feng a , Shawn D. St. Peter b , Saleem Islam c , Adam B. Goldin d , Fizan Abdullah e , Shawn J. Rangel a, ⁎ a Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts b Children's Mercy Hospitals & Clinics, Kansas City, Missouri c University of Florida College of Medicine, Gainesville, Florida d Seattle Children's Hospital, Seattle, Washington e Johns Hopkins University, Baltimore, Maryland abstract article info Article history: Received 26 January 2014 Accepted 27 January 2014 Key words: Mechanical bowel preparation Non-absorbable oral antibioticsl colorectal surgery Antibiotic prophylaxis Purpose: It is well established through randomized trials that oral antibiotics given with or without a mechanical bowel preparation (MBP) prior to colorectal procedures reduce complications, while MBP given alone provides no benefit. We aimed to characterize trends surrounding bowel preparation in children and determine whether contemporary practice is evidence-based. Methods: Retrospective analysis of patients undergoing colorectal procedures at 42 children’s hospitals (1/2/ 2007-12/31/2011) was performed. Patients were analyzed for diagnosis, pre-admission status, and inpatient bowel preparation. Bowel preparation was considered evidence-based if oral antibiotics were utilized with or without a MBP. Results: 49% of all patients were pre-admitted (n = 5,473), and the most common diagnoses were anorectal malformations (55%), inflammatory bowel disease (26%), and Hirschsprung’s Disease (19%). The most common preparation approaches were MBP alone (54.3%), MBP + oral antibiotics (18.8%), and oral antibiotics alone (4.2%), although significant variation was found in hospital-specific rates for each approach (MBP alone: 0-96.1%, MBP + oral antibiotics: 0-83.6%, orals alone: 0-91.6%, p b 0.0001). Only 22.9% of all patients received an evidence-based preparation (range by hospital: 0-92.3%, p b 0.0001), and this rate decreased significantly during the five-year study period (27.6% in 2007 vs. 17.3% in 2011, p b 0.0001). Conclusion: According to the best available clinical evidence, less than a quarter of all children pre-admitted for elective colorectal procedures receive a bowel preparation proven to reduce infectious complications. © 2014 Elsevier Inc. All rights reserved. The rates of infectious complications associated with colorectal surgery are among the highest with respect to elective procedures performed in adults and children alike. Postoperative complications for patients with inflammatory bowel disease occur in up to 55% of patients, and patients undergoing colorectal operations for Hirsch- sprung’s disease may experience a complication in close to 40% of cases [1,2]. Given the relatively high burden of infectious complica- tions attributable to colorectal procedures, many prophylactic strategies have been utilized to mitigate these events in the perioperative setting. Intravenous antibiotics at the time of surgery are widely considered the standard of care in this regard, however opinions remain mixed about the role of mechanical bowel prepara- tion (MBP) and oral antibiotics as prophylactic adjuncts to further decrease the risk of complications. The published evidence examining the prophylactic effectiveness of MBP and non-absorbable oral antibiotics in adult colorectal surgery is fairly extensive. Several meta-analyses incorporating data from high-quality randomized controlled trials have firmly established that non-absorbable oral antibiotics used with or without a MBP significantly reduce complications, while the administration of a MBP alone (without oral antibiotics) provides no benefit. Although no published trial has compared oral antibiotics alone with oral antibiotics combined with a MBP, data from two large, prospective, multi-center colorectal outcomes databases have suggested that oral antibiotics combined with a MBP significantly reduce infectious complications compared with MBP alone [3,4]. From this pool of relatively high-quality clinical evidence, two conclusions surrounding colorectal prophylaxis can be reached: 1) Oral non-absorbable antibiotics should be administered (with or without a MBP) as a prophylactic adjunct to intravenous antibiotics for elective colorectal procedures, and 2) MBP should never be given alone (without oral antibiotics) for this purpose. Journal of Pediatric Surgery 49 (2014) 1030–1035 ⁎ Corresponding author at: Boston Children’s Hospital 300 Longwood Avenue, Fegan 3 Boston, MA 02115. Tel.: +1 617 355 3040; fax: +1 617 730 0752. E-mail address: Shawn.Rangel@childrens.harvard.edu (S.J. Rangel). http://dx.doi.org/10.1016/j.jpedsurg.2014.01.048 0022-3468/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg