Are Bactrim and Metronidazol a good combination for sequential therapy in children with complicated (gangrenous or perforated) acute appendicitis?

 I think this is a good componation as metranidazole works on anaerobes and bactrin works on other bacteria mostly gram-negatives.

Two questions please

Antibiotic association were given post-operatively or vs operation? I think tha in these cases operation is mandatory, so antibiotics will work better.

There are several protocols concerning antibiotics in appendicitis. Two main concerns are to be followed: Cost (different from country to country) and efficacity on local germs (mostly different from hospital to hospital). that's why it's so important to build, with the help of your infectiologists, a hospital protocol that may evolve with time.

last: I have the same question as above; Why choose for antibiotics that you have to change after few days (from IV to oral)?  

To Dr Rakesh Handa,they probably switched therapy to an oral one to send the kids back home, so it is good at a certain point to have an oral therapy, but still, I really like to see the results too!

I think that could be a good combination but swabs collection to compare the etiology and establish the antibiogram to have an effective proof of your good results, would be better. Some organisms are resistant to Bactrim, Pseudomonas for instance, so if you do not isolate the microorganism before giveing the antibiotic therapy, you risck to give a usless one.

Greetings,

Ramona.

The historical treatment(2006-2009) for complicated (gangrenous or perforated) acute appendicitis at the Pediatric Teaching Hospital of Camagüey, Cuba, included Ceftriaxone, Amikacin and Metronidazole between seven and ten days. The length of hospital stay was 7.03 days/patient, the cost was more than 950 USD/children and the infection rate was 8. 45 %.

Since 2010, the protocol used at the Pediatric Surgery Service of Camagüey, included a three days treatment with Ceftriaxone plus Metronidazol in children with intraoperative findings of gangrenous acute appendicitis. For children with perforated acute appendicitis with or without secondary peritonitis, Amikacin also was included for five days. After that, if the children are being able to eat and have not got fever for the last 24 hours, they go home with seven days treatment of Bactrim and Metronidazole P.O.

Between 2010 and 2013, 93 % of children with complicated acute appendicitis were included on this sequential program.The length of hospital stay was 4.2 days/patient, the cost was 578 USD/children and the infection rate was 6. 38 %.

It really sounds good!

But I still advice you to check on the microorganism to compare the results and have a more targeting therapy then an empiric one.

Best regards.

To Jose Carlos

Thanks for details of the antibiotic therapy used in the Cuban study. However, don't you think that it is too much of antibiotic even for a complicated / perforated appendicitis? Five days of IV Ceftriaxone and Metronidazole followed by 7 days of Bactrim and Metronidazole??

We would use only 5 days (max 7 days in very severe fecal peritonitis) of antibiotics including the oral medication. I personally do not give any Metronidazole after 5 days. 

Suggest a study to see if, after the 5 days of IV antibiotic you have given, does it even provide any additional benefit to give the 7 days of Bactrim +Metronidazole PO. You can create 2 arms and one is given the 7 days of oral medication and the other is not. The results may be surprising !!

Well, the key stone here is the surgery. the antibiotics you have mentioned are more than enough. Adding trimethoprime sulphametoxazole (Septrim) to the medication will add nothing in my opinion.

However, I am  from a challenged resource settings nation where we do use Septim or Bactrim in many paediatric infections such as UTI, mesentric Lymphadinitis, tosilitis, etc.

Cure rate is excellent based on no sulpha contraindications, yet, we have no experience with it in peritonitis

In case of complicated and gangrenous acute appendicitis - Antibiotics that have broad coverage for facultative and anaerobic colonic flora should be used. Options are ceftriaxone+Metronidazole or Piperacillin+Tazobactum or Imipenem+cilastin should be used and the duration of therapy is 4 to 7 days until the symptoms subsides.

In a limited resource hospital, the microbiological studies have some difficulties, therefore isolation of microorganisms and its sensibility are not as well as some institution need. A reviewing of the most important papers concerning to sequential, switch and step down antibiotic therapy for children with complicated acute appendicitis, was carried out at the Pediatric Surgery Service for the last four years, in order to improve our health care offer (length of hospital stay, cost and infection rate).

If you have limited resources this sounds as the best way.

Anyway, you could try to test at least the 2 antibiotics you use, just to be more sure you're doing good. To the practical aim, it is not necessary to isolate all the pathogens, you could simply use 2 blood agar plates and a surgical swab. Sow your swab on the agars and incubate them at 37°C over night with the antibiotic disk on it  (one in aerobiosis, one in anaerobiosis) (MTZ in ana and SXT in aero). If you have really restricted resources, you could simply use the "candle-jar" for the anaerobic culture and let everything at room temperature (guessing tthat in Cuba is really hot), after 18/20 hours you should have your resaults as well.

Dear Dr. Carlos-Rodriguez,

With limited or nonexistent means  your  best protocol is what we did in the 1950"s. and 60's, and 70's, to wit:: " Mutilate DO NOT MUTATE the bacteria.." is better than trying to " scientifically sharpshooter" the bacteria..

We never use this antibiotic combination in the tretment of  perforated appendicitis. in  pediatric patients.

The  combination  is  amikacina with metronidazole or  amikacina with third  generation cefalosporins.(efotaxime)

With  this  treatment  we have nothing postoperatory complication.

Well, it seems very good concerning the cost. However, you may be confronted with cases of haemolytic anemia  such as G6PD anemia