Download PDF
Eur J Pediatr Surg 2014; 24(04): 341-349
DOI: 10.1055/s-0033-1349055
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Duration of Postoperative Intravenous Antibiotics in Childhood Complicated Appendicitis: A Propensity Score-Matched Comparison Study

Tzu-Chieh Yu
1   Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand
2   Department of Paediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
,
James K. M. Hamill
2   Department of Paediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
,
Stephen M. Evans
2   Department of Paediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
,
Neil R. Price
2   Department of Paediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
,
Philip N. Morreau
2   Department of Paediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
,
Vipul A. Upadhyay
2   Department of Paediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
,
R. Stuart Ferguson
2   Department of Paediatric Surgery and Urology, Starship Children's Hospital, Auckland, New Zealand
,
Emma J. Best
3   Department of Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
,
Andrew G. Hill
1   Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand
› Author Affiliations
Further Information

Publication History

19 January 2013

23 May 2013

Publication Date:
25 June 2013 (online)

    Permissions and Reprints

Abstract

Introduction Postoperative antibiotics complement surgery in managing childhood-complicated appendicitis. However, there is limited evidence to guide clinicians on appropriate duration of therapy. A comparison cohort study was performed to determine whether tailoring duration of inpatient intravenous (IV) antibiotic therapy to patient response, assessed using a set of clinical criteria, leads to shortened hospital length of stay (LOS) without compromising patient outcomes.

Patients and Methods Over a 6-month period, 47 children (aged 5–14 years) with complicated appendicitis were treated with postoperative IV antibiotics until each satisfied a set of bedside clinical parameters suggesting resolved intraperitoneal infection (core temperature < 38°C for 24 hours, tolerated two consecutive meals, mobilizing independently, requiring only oral analgesia). Complicated appendicitis was defined as the presence of generalized peritonitis, appendiceal perforation or gangrene, and/or abscess. Postoperative recovery parameters were prospectively recorded and compared with those of 47 historical control patients, matched by propensity scores, who received 5 days minimum of postoperative IV antibiotics. Sample size was determined by a priori power calculation based on reduction in LOS. Severity of postoperative complications was graded using the Clavien–Dindo system.

Results Study group variables were comparable including patient demographics, duration of presenting symptoms, severity of presenting disease, preoperative antibiotics received, length of operation, seniority of primary surgeon, surgical approach taken, and intraoperative findings. The prospective cohort had a significantly shorter median LOS compared with the historical control cohort (5 vs. 6 nights, p = 0.010) while readmission rates and the incidence and severity of complications were similar, including incidence of postoperative intra-abdominal infections (6 vs. 8 cases, p = 0.562).

Conclusion Using bedside clinical parameters indicative of resolved intraperitoneal infection to tailor duration of postoperative IV antibiotics for children with complicated appendicitis shortens LOS without apparent compromise to patient outcomes.

Keywords

complicated appendicitis - antibiotic therapy - length of stay - secondary peritonitis - postoperative complications
 

  • References

  • 1 Henderson J, Goldacre MJ, Fairweather JM, Marcovitch H. Conditions accounting for substantial time spent in hospital in children aged 1-14 years. Arch Dis Child 1992; 67 (1) 83-86
    CrossrefPubMedGoogle Scholar
  • 2 Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis?. JAMA 1996; 276 (19) 1589-1594
    CrossrefPubMedGoogle Scholar
  • 3 Carr NJ. The pathology of acute appendicitis. Ann Diagn Pathol 2000; 4 (1) 46-58
    CrossrefPubMedGoogle Scholar
  • 4 Lee J, Tashjian DB, Moriarty KP. Missed opportunities in the treatment of pediatric appendicitis. Pediatr Surg Int 2012; 28 (7) 697-701
    CrossrefPubMedGoogle Scholar
  • 5 Haecker FM, Fasler-Kan E, Manasse C, Fowler B, Hertel R, von Schweinitz D. Peritonitis in childhood: clinical relevance of cytokines in the peritoneal exudate. Eur J Pediatr Surg 2006; 16 (2) 94-99
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Hamilton NA, Mazuski JE. Antimicrobial and surgical management of intra-abdominal infections in children. J Pediatr Infect Dis 2009; 4: 37-45
    PubMedGoogle Scholar
  • 7 Perdue PW, Kazarian KK, Nevola J, Law WR, Williams T. The use of local and systemic antibiotics in rat fecal peritonitis. J Surg Res 1994; 57 (3) 360-365
    CrossrefPubMedGoogle Scholar
  • 8 Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ. 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2010; 45 (11) 2181-2185
    CrossrefPubMedGoogle Scholar
  • 9 Snelling CM, Poenaru D, Drover JW. Minimum postoperative antibiotic duration in advanced appendicitis in children: a review. Pediatr Surg Int 2004; 20 (11-12) 838-845
    CrossrefPubMedGoogle Scholar
  • 10 Mazuski JE, Sawyer RG, Nathens AB , et al; Therapeutic Agents Committee of the Surgical Infections Society. The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: evidence for the recommendations. Surg Infect (Larchmt) 2002; 3 (3) 175-233
    CrossrefPubMedGoogle Scholar
  • 11 Chen C, Botelho C, Cooper A, Hibberd P, Parsons SK. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg 2003; 196 (2) 212-221
    CrossrefPubMedGoogle Scholar
  • 12 Nadler EP, Gaines BA. Therapeutic Agents Committee of the Surgical Infection Society. The Surgical Infection Society guidelines on antimicrobial therapy for children with appendicitis. Surg Infect (Larchmt) 2008; 9 (1) 75-83
    CrossrefPubMedGoogle Scholar
  • 13 Solomkin JS, Mazuski JE, Bradley JS , et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50 (2) 133-164
    CrossrefPubMedGoogle Scholar
  • 14 Keller MS, McBride WJ, Vane DW. Management of complicated appendicitis. A rational approach based on clinical course. Arch Surg 1996; 131 (3) 261-264
    CrossrefPubMedGoogle Scholar
  • 15 Taylor E, Dev V, Shah D, Festekjian J, Gaw F. Complicated appendicitis: is there a minimum intravenous antibiotic requirement? A prospective randomized trial. Am Surg 2000; 66 (9) 887-890
    PubMedGoogle Scholar
  • 16 Hoelzer DJ, Zabel DD, Zern JT. Determining duration of antibiotic use in children with complicated appendicitis. Pediatr Infect Dis J 1999; 18 (11) 979-982
    CrossrefPubMedGoogle Scholar
  • 17 Bensard DD, Hendrickson RJ, Fyffe CJ, Careskey JM, Azizkhan RG. Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway. J Laparoendosc Adv Surg Tech A 2009; 19 (Suppl. 01) S81-S86
    CrossrefPubMedGoogle Scholar
  • 18 Clavien PA, Barkun J, de Oliveira ML , et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250 (2) 187-196
    CrossrefPubMedGoogle Scholar
  • 19 Adamina M, Guller U, Weber WP, Oertli D. Propensity scores and the surgeon. Br J Surg 2006; 93 (4) 389-394
    CrossrefPubMedGoogle Scholar
  • 20 D'Agostino Jr RB. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 1998; 17 (19) 2265-2281
    CrossrefPubMedGoogle Scholar
  • 21 Adibe OO, Barnaby K, Dobies J , et al. Postoperative antibiotic therapy for children with perforated appendicitis: long course of intravenous antibiotics versus early conversion to an oral regimen. Am J Surg 2008; 195 (2) 141-143
    CrossrefPubMedGoogle Scholar
  • 22 Fraser JD, Aguayo P, Leys CM , et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg 2010; 45 (6) 1198-1202
    CrossrefPubMedGoogle Scholar
  • 23 Gollin G, Abarbanell A, Moores D. Oral antibiotics in the management of perforated appendicitis in children. Am Surg 2002; 68 (12) 1072-1074
    PubMedGoogle Scholar
  • 24 Styrud J, Eriksson S, Granström L. Treatment of perforated appendicitis: an analysis of 362 patients treated during 8 years. Dig Surg 1998; 15 (6) 683-686
    CrossrefPubMedGoogle Scholar
  • 25 Wacha H, Warren B, Bassaris H, Nikolaidis P. Intra-Abdominal Infections Study Group. Comparison of sequential intravenous/oral ciprofloxacin plus metronidazole with intravenous ceftriaxone plus metronidazole for treatment of complicated intra-abdominal infections. Surg Infect (Larchmt) 2006; 7 (4) 341-354
    CrossrefPubMedGoogle Scholar
  • 26 Solomkin JS, Reinhart HH, Dellinger EP , et al; The Intra-Abdominal Infection Study Group. Results of a randomized trial comparing sequential intravenous/oral treatment with ciprofloxacin plus metronidazole to imipenem/cilastatin for intra-abdominal infections. Ann Surg 1996; 223 (3) 303-315
    CrossrefPubMedGoogle Scholar
  • 27 Rice HE, Brown RL, Gollin G , et al. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. Arch Surg 2001; 136 (12) 1391-1395
    CrossrefPubMedGoogle Scholar
  • 28 Taylor E, Berjis A, Bosch T, Hoehne F, Ozaeta M. The efficacy of postoperative oral antibiotics in appendicitis: a randomized prospective double-blinded study. Am Surg 2004; 70 (10) 858-862
    PubMedGoogle Scholar
  • 29 Alamili M, Gögenur I, Rosenberg J. Oral antibiotics for perforated appendicitis is not recommended. Dan Med Bull 2010; 57 (9) A4177
    PubMedGoogle Scholar
  • 30 King DR, Browne AF, Birken GA, Hilty MD, Kerzner B, Boles Jr ET. Antibiotic management of complicated appendicitis. J Pediatr Surg 1983; 18 (6) 945-950
    CrossrefPubMedGoogle Scholar
  • 31 Neilson IR, Laberge JM, Nguyen LT , et al. Appendicitis in children: current therapeutic recommendations. J Pediatr Surg 1990; 25 (11) 1113-1116
    CrossrefPubMedGoogle Scholar
  • 32 Birken GA, Schropp KP, Boles Jr ET, King DR. Discharge planning for children with perforated appendicitis. J Pediatr Surg 1986; 21 (7) 592-595
    CrossrefPubMedGoogle Scholar
  • 33 Emil S, Laberge JM, Mikhail P , et al. Appendicitis in children: a ten-year update of therapeutic recommendations. J Pediatr Surg 2003; 38 (2) 236-242
    CrossrefPubMedGoogle Scholar
  • 34 Lose G, Holm B, Bauer T , et al. The predictive value of the third day temperature in the decision whether to continue or terminate antibiotic treatment in perforated appendicitis. Ann Chir Gynaecol 1987; 76 (4) 201-203
    PubMedGoogle Scholar
  • 35 Lund DP, Murphy EU. Management of perforated appendicitis in children: a decade of aggressive treatment. J Pediatr Surg 1994; 29 (8) 1130-1133 , discussion 1133–1134
    CrossrefPubMedGoogle Scholar
  • 36 Schwartz MZ, Tapper D, Solenberger RI. Management of perforated appendicitis in children. The controversy continues. Ann Surg 1983; 197 (4) 407-411
    CrossrefPubMedGoogle Scholar
  • 37 Fishman SJ, Pelosi L, Klavon SL, O'Rourke EJ. Perforated appendicitis: prospective outcome analysis for 150 children. J Pediatr Surg 2000; 35 (6) 923-926
    CrossrefPubMedGoogle Scholar
  • 38 St Peter SD, Tsao K, Spilde TL , et al. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg 2008; 43 (6) 981-985
    CrossrefPubMedGoogle Scholar
  • 39 Ciftci AO, Tanyel FC, Büyükpamukçu N, Hiçsonmez A. Comparative trial of four antibiotic combinations for perforated appendicitis in children. Eur J Surg 1997; 163 (8) 591-596
    PubMedGoogle Scholar
  • 40 St Peter SD, Sharp SW, Holcomb III GW, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 2008; 43 (12) 2242-2245
    CrossrefPubMedGoogle Scholar