A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial

Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA.
Journal of Pediatric Surgery (Impact Factor: 1.39). 06/2010; 45(6):1198-202. DOI: 10.1016/j.jpedsurg.2010.02.090
Source: PubMed


In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics.
Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days.
One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm.
When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.

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    • "However, several prospective trials have been conducted since that time adding to our base of medical knowledge. A series of prospective trials at our institution resulted in protocols for patients with perforated appendicitis [4] [5] [6]. In this study, we sought to evaluate the differences in resource utilization between individualized and protocol-based management. "
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    ABSTRACT: We instituted a clinical pathway for the care of patients with perforated appendicitis based on outcomes from several clinical trials. The objective of this study was to review effects on resource utilization with this protocol. A retrospective review was conducted to compare all patients undergoing appendectomy during initial admission for perforated appendicitis prior to the pathway (July 2001 to December 2003) to after (December 2008 to March 2011). Demographics and management strategies were evaluated. Charts of 151 patients prior to and 259 after the start of the pathway were reviewed. The percentage of patients leaving the operating room with a nasogastric tube (NGT) was significantly lower in the after-group, while similar numbers of patients during each period had a NGT placed on the floor. The proportion of patients receiving peripherally inserted central catheters and total parenteral nutrition, and the number of intravenous antibiotics per day and lab draws were significantly reduced with the protocol. Patients were started on a regular diet significantly earlier, and length of stay was shortened by more than one day. The evidence-based clinical pathway developed from prospective trials has drastically reduced resource utilization for children with perforated appendicitis.
    Journal of Pediatric Surgery 06/2013; 48(6):1395-1398. DOI:10.1016/j.jpedsurg.2013.03.044 · 1.39 Impact Factor
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    • "Acute appendicitis is the most common cause of acute abdominal pain requiring surgical intervention, and it is the most frequently performed emergency operation.1 The efficacy of antibiotic prophylaxis in patients undergoing appendectomy has been examined in several studies.2–11 Without any pre- or perioperative antibiotic prophylaxis, wound infection rates in patients undergoing appendectomy are 10% or more when the appendix is normal, increasing to 30% when the appendix is phlegmonous or gangrenous.12 "
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    ABSTRACT: The rate of wound infection after appendectomy without antibiotic prophylaxis is 10%-30%. The role of prophylactic antibiotic therapy in nonperforated appendicitis is still controversial. Metronidazole is against anaerobic organisms and its bioavailability after oral and parenteral administration has been shown to be similar. The objective of the present study is to compare the infective complications rate after open appendectomy for nonperforated appendicitis receiving either oral or intravenous metronidazole as prophylaxis. From June 2007 to July 2009 in a randomized controlled trial, 204 patients with nonperforated appendicitis underwent an open appendectomy; 122 male and 82 female with mean age of 25 years. Among these, 102 (case group) received oral metronidazole and in 102 (control group) metronidazole was administered intravenously before surgery. The rate of wound infection and duration of the postoperative hospital stay was studied in the two groups. The rate of wound infection was not significantly different in the two groups. (6% and 4% in study and control group, respectively, P = 0.861). Also the hospital stay was equal in two groups (2.3 days and 2.7 days in study and control group, respectively, P = 0.293). Single dose of oral metronidazole prior to operation can provide a sufficient prophylaxis for nonperforated appendicitis; so, it can be substitute the parental route of antibiotic administration.
    Clinical and Experimental Gastroenterology 12/2011; 4(1):273-6. DOI:10.2147/CEG.S18153
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    • "In our previous 3 trials, we found the postoperative abscess rate to be approximately 20% regardless of the variables introduced [4] [5] [6]. Herein, we found the abscess rate is dramatically higher in obese patients. "
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    ABSTRACT: Purpose Obesity is an increasing problem in the pediatric population. Despite abundant data on the impact of obesity in adults, little data exists that examines the impact of obesity on surgical outcomes in children. Therefore, we reviewed our experience with perforated appendicitis to evaluate the impact of obesity. Methods We reviewed the results of patients enrolled in 3 prospective trials on perforated appendicitis between 2005 and 2009. Perforation was defined as a hole in the appendix or fecalith in abdomen. There was no difference in abscess rate in the variables studied in these trials. All patients underwent laparoscopic appendectomy. In this study we evaluated demographics, presentation data, operative time and outcome variables relative to body mass index (BMI). BMI was calculated and plotted on growth chart to obtain BMI percentage according to gender and age. The obese group was defined as BMI > 95th percentile. Outcomes were compared between non-obese and obese patients using student’s T test for continuous variables and Chi square for discrete variables. Results There were 220 patients identified, 183 patients were non-obese and 37 patients were obese. The obese group was older at an average 11.2 years versus 8.6 years for the non-obese group (P = 0.001). The groups have no difference in duration of symptoms before presentation. Mean length of stay was 7.9 days in the obese patients compared to 5.8 days for the non-obese (P < 0.001). Mean operative time was 55.2 minutes in obese patients compared to 43.6 minutes for non-obese (P = 0.002). Abscess rate was 35% in obese patients compared to 14% for non-obese (P= 0.004). Conclusion Obese children undergoing laparoscopic appendectomy for perforated appendices experience longer operative times and suffer worse outcomes then non-obese children.
    2010 American Academy of Pediatrics National Conference and Exhibition; 10/2010
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