Is there new evidences concerning to the use of sequential (intravenous/oral) antibiotics on children with complicated acute appendicitis?

The Initial treatment with intravenous antibiotics significantly reduces wound infection and intraabdominal abscess formation for patients with gangrenous or perforated appendicitis . In retrospective series, therapy with a single antibiotic (such as piperacillin/tazobactam, cefoxitin, or ceftriaxone) appears to be as effective as multiple antibiotic therapy (such as ampicillin, gentamicin, and metronidazole) for preventing complications of perforated appendicitis, as measured by length of hospital stay and readmission rates and is more cost effective.

In a prospective randomized controlled trial of 98 children with perforated appendicitis, metronidazole (30 mg/kg as a single daily dose) and ceftriaxone (50 mg/kg as a single daily dose) was as effective as standard multiple daily doses of ampicillin, gentamicin, and clindamycin in preventing abscess or wound infection . Length of hospitalization was similar between groups. However, patients who received the simplified regimen incurred significantly lower antibiotic charges.

Evidence regarding the optimum duration of antibiotic therapy is limited. Many pediatric surgeons use resolution of pain, return of bowel function, normalization of white blood cells (WBC), and absence of fever as indications to discontinue intravenous antibiotics, and this approach is endorsed by the American Pediatric Surgical Association . In some of these patients, fever may be a poor predictor of infection .

A systematic review of postoperative antibiotic duration for children with advanced appendicitis noted that children treated with intravenous antibiotics for three days did not have an increased number of infectious complications compared with those treated for longer periods . However, a minimum of five days of intravenous antibiotics is recommended by the American Pediatric Surgical Association, and it is common practice among pediatric surgeons to treat for up to seven days or longer depending upon the patient’s clinical response .

We continue intravenous antibiotics in children with advanced appendicitis until they are afebrile, well controlled on oral analgesics and tolerating a regular diet. We discharge them when they meet these criteria, but we also follow their white blood cell count, and if it is still elevated, we discharge them on a seven-day course of amoxicillin and clavulanate potassium (Augmentin). This approach is supported by the following studies:

●In a retrospective observational study of 304 children with ruptured appendicitis that compared intravenous antibiotic duration determined by clinical response and oral antibiotic therapy at discharged determined by WBC to antibiotic duration of at least four days (152 patients) with no oral antibiotics at discharge, patients whose duration of antibiotics was determined by clinical response went home, on average 39 hours sooner than patients who received at least four days of intravenous antibiotics regardless of clinical findings (mean length of stay 95 versus 134 hours, respectively) with significant cost savings . There was no difference in abdominal abscesses, reoperations, interventional radiology drainage of abscess, or inpatient readmission between the groups.

●The use of oral antibiotic after discharge is also supported by a prospective trial of 100 children with perforated appendicitis, 42 percent underwent discharge on oral antibiotics (amoxicillin and clavulanate potassium, Augmentin) to complete a seven day course of antibiotics prior to postoperative day five without a discernable increase in postoperative abscesses .

Children, who are still febrile and/or unable to tolerate a regular diet 7 to 10 days after surgery, should have diagnostic imaging studies to search for an abdominal or pelvic abscess.