Simplification of first-line antibacterial regimen for complicated appendicitis in children is associated with better adherence to guidelines and reduced use of antibiotics
Introduction
Acute appendicitis is a common surgical condition affecting 0.3–0.4% of children, with a peak incidence between 8–13 years of age. The most common complications include perforation, peritonitis and abscess, found in 25–39% of cases [1]. Treatment of acute appendicitis usually relies on early surgery (appendectomy and, when necessary, management of complications) and a short course of antibiotics (4–7 days) [2], although highly selected patients with a well circumscribed focus of infection may be cured by antimicrobial therapy alone [3]. An aminoglycoside-containing three-drug regimen has been used successfully for decades to treat complicated intra-abdominal infections in children, although simpler regimens, such as broad-spectrum β-lactam/β-lactamase inhibitor combinations, are of similar efficacy [3], [4], [5], [6].
In March 2013, a local multidisciplinary group of professionals involved in the care of children with appendicitis, including a paediatric surgeon, anaesthesiologist, microbiologist and infectious diseases physician, modified the first-line antibacterial treatment of appendicitis for children in our institution, with two objectives: (i) to decrease the complexity of workload for nurses and the rates of deviation from the previous protocol, i.e. the triple combination of cefotaxime, gentamicin and metronidazole; and (ii) to reduce the rate of post-operative intra-abdominal abscess from a baseline range of 15–20% in 2008–2012. In April 2013, piperacillin/tazobactam (TZP) became the first-line regimen for all children operated for complicated appendicitis and was incorporated in the computerised system for drug prescription, with standard duration, intervals and weight-based dosing. In addition, a specific note against the use of oral switch beyond Day 5 for children with a favourable outcome was added in the protocol. The main objective of this study was to evaluate the impact of these protocol changes on the incidence of post-operative complications. Secondary objectives were evaluation of protocol deviations and analysis of risk factors for post-operative intra-abdominal abscess.
Section snippets
Study design
A retrospective, observational study of all children aged <18 years who underwent surgery for complicated appendicitis from April 2011 to March 2015 in Rennes University Hospital (Rennes, northwest France) was performed. Cases were identified through the computerised database of the paediatric surgery department. Complicated appendicitis was defined as appendicitis requiring surgery associated with at least one of the following reported in the surgery report: (i) abscess; (ii) local
Results
During the study period (April 2011 to March 2015), 171 children operated for acute appendicitis fulfilled the inclusion criteria, including 80 from April 2011 to March 2013 (G1) and 91 from April 2013 to March 2015 (G2). Baseline characteristics and management were similar in both groups (Table 1), except for surgical technique, as appendectomy was performed through laparoscopy in 88% of children in G2 compared with only 46% in G1 (P < 0.001). The incidence and characteristics of
Discussion
The major findings of this study are as follows: (i) simplification of first-line antibacterial treatment for children with complicated appendicitis, from an aminoglycoside-containing three-drug regimen (cefotaxime + metronidazole + gentamicin) to a broad-spectrum β-lactam/β-lactamase inhibitor combination (TZP) was not associated with any significant change in terms of post-operative complications; (ii) a specific recommendation against the use of oral switch after discharge for children with
Funding
None.
Competing interests
None.
Ethical approval
This study was approved by the Institutional Review Board of Rennes University Hospital (Rennes, France).
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Cited by (8)
Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam Versus Ceftriaxone with Metronidazole
2023, Journal of Pediatric SurgeryCeftriaxone with Metronidazole versus Piperacillin/Tazobactam in the management of complicated appendicitis in children: Results from a multicenter pediatric NSQIP analysis
2022, Journal of Pediatric SurgeryCitation Excerpt :Furthermore, measures of resource utilization were similar between groups, with no differences found in rates of postoperative abdominal imaging, 30-day cumulative postoperative length of stay or cumulative hospital cost. The results of this study add to the growing body of evidence suggesting that routine use of extended spectrum anti-Pseudomonal agents may not be necessary in the management of acute appendicitis in children [7,11,14,16,19]. To our knowledge, the present study represents the first multicenter analysis using a standardized definition for complicated appendicitis, a rigorous chart review process by trained NSQIP personnel, and a validated approach to adjust for differences in disease severity among groups.
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