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Keane OA, Motley T, Robinson J, Smith A, Short HL, Santore MT. Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative. J Pediatr Surg 2024; 59:1058-1065. [PMID: 38030531 DOI: 10.1016/j.jpedsurg.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative. METHODS On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation. RESULTS In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001). CONCLUSION Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care. STUDY TYPE Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Theresa Motley
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jenny Robinson
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alexis Smith
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Snyder KB, Hunter CJ, Buonpane CL. Perforated Appendicitis in Children: Management, Microbiology, and Antibiotic Stewardship. Paediatr Drugs 2024; 26:277-286. [PMID: 38653916 DOI: 10.1007/s40272-024-00630-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
Abstract
Although appendicitis has been described for more than 300 years, its optimal management remains a topic of active investigation. Acute appendicitis is the most common cause of peritonitis in children, and rates of perforated appendicitis are much higher in children than in adults. Increased risk for perforated appendicitis in children is related to a delay in diagnosis due to age, size, access to care, and more. Surgical options include immediate appendectomy versus nonoperative management with intravenous antibiotics ± a drainage procedure, with a subsequent interval appendectomy. Microbiota of perforated appendicitis in children most often includes Escherichia coli, Bacteroides fragilis, Streptococcus, and more. Even though the most common organisms are known, there is a large variety of practice when it comes to postoperative antibiotic management in these patients. Studies discuss the benefits of mono- versus dual or triple therapy without a particular consensus regarding what to use. This is reflected across differing practices at various institutions. In this review, we aim to explore the implications of perforated appendicitis in pediatrics, common organisms seen, antibiotic regimen coverage, and the implications of variations of practice. Resistance to commonly used broad-spectrum antibiotics is evolving, therefore minimization of care variability is needed for improved patient outcomes and proper antibiotic stewardship.
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Beckermann J, Linnaus ME, Swartz H, Stewart S, York J, Gassner RR, Kasal CA, Seidel AG, Wachter CJ, Kooda KJ, Rich JR, Sawyer MD. Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study. Surgery 2024; 175:1352-1357. [PMID: 38413304 DOI: 10.1016/j.surg.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND To decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections. METHODS The aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention. RESULTS A total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups. CONCLUSION Our quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.
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Affiliation(s)
- Jason Beckermann
- General and Trauma Surgery, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI.
| | - Maria E Linnaus
- General and Trauma Surgery, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI
| | | | | | | | | | - Christopher A Kasal
- General Surgery, Mayo Clinic Health System-Southeast Minnesota region, Red Wing, MN
| | - Annaliese G Seidel
- Department of Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Corey J Wachter
- Pharmacy Services, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI
| | - Kirstin J Kooda
- Pharmacy Services, Critical Care, and General Surgery (Sawyer), Mayo Clinic, Rochester, MN
| | - Jennifer R Rich
- Research & Innovation, Mayo Clinic Health System-Northwest Wisconsin region, Eau Claire, WI
| | - Mark D Sawyer
- Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
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Cironi K, Albuck AL, McLafferty B, Mortemore AK, McCarthy C, Hussein M, Issa PP, Metz T, Herrera M, Toraih E, Taghavi S, Kandil E, Turner J. Risk Factors for Postoperative Infections Following Appendectomy of Complicated Appendicitis: A Meta-analysis and Retrospective Single-institutional Study. Surg Laparosc Endosc Percutan Tech 2024; 34:20-28. [PMID: 37852230 DOI: 10.1097/sle.0000000000001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/22/2023] [Indexed: 10/20/2023]
Abstract
Patients with complicated appendicitis have an increased risk for postoperative infections. Potential risk factors for postoperative infections through a meta-analysis and retrospective chart review are discussed. A meta-analysis consisting of 35 studies analyzing complicated appendicitis treated with an appendectomy noting at least 1 postoperative infection was performed. A retrospective review was then conducted in patients diagnosed with complicated appendicitis after appendectomy. Of 5326 patients in total, 15.4% developed postoperative infections. Laparoscopic surgery and perioperative hyperoxygenation were found to be protective factors for the development of infection. Retrospectively, 53.2% of patients presented with complicated appendicitis. Patients with complicated appendicitis were more likely to be older in age and have an increased length of stay. Patient demographics, operative time, and comorbid status had no effect on postoperative infection or readmission rate. Physicians should strongly consider minimally invasive techniques to treat all cases of complicated appendicitis irrespective of comorbidities, age, sex, or body mass index.
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Affiliation(s)
| | | | | | | | | | | | - Peter P Issa
- Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA
| | | | | | - Eman Toraih
- Department of Surgery, Division of Endocrine and Oncologic Surgery
- Department of Genetics, Histology and Cell Biology, Suez Canal University Faculty of Medicine, Ismailia, Egypt
| | - Sharven Taghavi
- Department of Surgery, Division of Trauma and Critical Care, Tulane University School of Medicine
| | - Emad Kandil
- Department of Surgery, Division of Endocrine and Oncologic Surgery
| | - Jacquelyn Turner
- Department of Surgery, Division of Endocrine and Oncologic Surgery
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Stewart S, Cruz-Centeno N, Marlor DR, St Peter SD, Oyetunji TA. Bridging the Gap: Pediatric General Surgery for the Pediatrician. Pediatr Rev 2023; 44:632-643. [PMID: 37907417 DOI: 10.1542/pir.2022-005894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
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Cramm SL, Chandler NM, Graham DA, Kunisaki SM, Russell RT, Blakely ML, Lipskar AM, Allukian M, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Cowles RA, DeFazio JR, Esparaz JR, Feng C, Griggs CL, Guyer RA, Hanna DN, Kahan AM, Keane OA, Lamoshi A, Lopez CM, Pace E, Regan MD, Santore MT, Scholz S, Tracy ET, Williams SA, Zhang L, Rangel SJ. Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis. Ann Surg 2023; 278:e863-e869. [PMID: 36317528 DOI: 10.1097/sla.0000000000005747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. BACKGROUND Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision. METHODS This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. RESULTS A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. CONCLUSIONS Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Robert A Cowles
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Cornelia L Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Richard A Guyer
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Anastasia M Kahan
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
- Department of Surgery, Mount Sinai Health System, New York, NY
| | - Olivia A Keane
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Carla M Lopez
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth Pace
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maia D Regan
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Stefan Scholz
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Sacha A Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Lucy Zhang
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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van den Boom AL, de Wijkerslooth EM, Giesen LJ, van Rossem CC, Toorenvliet BR, Wijnhoven BP. Postoperative Antibiotics and Time to Reach Discharge Criteria after Appendectomy for Complex Appendicitis. Dig Surg 2023; 39:162-168. [PMID: 36041400 PMCID: PMC9909712 DOI: 10.1159/000526790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/16/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Postoperative antibiotic treatment is indicated for 3-5 days following appendectomy for complex appendicitis. However, meeting discharge criteria may allow for safe discontinuation of antibiotics and discharge. This study assessed the association between time to reach discharge criteria and duration of postoperative antibiotic use and length of stay. METHODS This is a multicenter retrospective cohort study including patients who underwent appendectomy for complex appendicitis and received postoperative antibiotics for >24 h. Main outcome measures were time to reach discharge criteria, duration of postoperative antibiotic use, length of hospital stay, and postoperative infectious complications. Discharge criteria were defined as absence of fever (temperature ≤38°C) for 24 h, ability to tolerate oral intake, and pain controlled by oral analgesics. RESULTS Between May 2014 and January 2015, 124 patients were included. Time to reach discharge criteria was 2 days (interquartile range [IQR] 1-3). Patients received postoperative antibiotics and were in hospital for a median of 5 (IQR 3-5) and 5 (IQR 4-6) days, respectively. Infectious complications occurred in 12% and did not differ between patients reaching discharge criteria before or after 2 postoperative days. DISCUSSION Discharge criteria were met by a median of 2 days after appendectomy for complex appendicitis. This suggests that postoperative antibiotics duration and thereby hospital stay can be reduced. In daily practice, prescribed antibiotics are not reduced in total days given. Prospective studies that evaluate limited postoperative antibiotic use, based on these criteria, are necessary.
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Affiliation(s)
- Anne Loes van den Boom
- Department of Surgery, Erasmus MC − University Medical Centre, Rotterdam, The Netherlands,*Anne Loes van den Boom, a.vandenboomüerasmusmc.nl
| | | | - Louis J.X. Giesen
- Department of Surgery, Erasmus MC − University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Bas P.L. Wijnhoven
- Department of Surgery, Erasmus MC − University Medical Centre, Rotterdam, The Netherlands
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Hu A, Li J, Vacek J, Bouchard M, Ingram MC, McMahon M, Mithal LB, Raval MV, Reynolds M, Goldstein S. Antibiotic resistance is common in the cultures of intraabdominal abscess drainage after appendectomy. J Pediatr Surg 2022; 57:102-106. [PMID: 34991867 DOI: 10.1016/j.jpedsurg.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/14/2021] [Accepted: 12/04/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Intraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis. METHODS We performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected. RESULTS In total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage. CONCLUSIONS IAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Jennifer Li
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jonathan Vacek
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan Bouchard
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Martha-Conley Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Maxwell McMahon
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Leena B Mithal
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Seth Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Parental Knowledge of Appendicitis and Preference for Operative or Non-Operative Treatment at a United Kingdom Children’s Hospital. CHILDREN 2022; 9:children9081191. [PMID: 36010083 PMCID: PMC9406866 DOI: 10.3390/children9081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/02/2022] [Accepted: 08/06/2022] [Indexed: 11/26/2022]
Abstract
Appendicitis is a common cause of abdominal pain in children, and is the most common reason for children to undergo emergency abdominal surgery. To guide our research program in this field, we aimed to determine parental understanding with regard to appendicitis and its treatment. We also wished to assess parental preference for non-operative or surgical treatment of children with uncomplicated appendicitis. We asked parents attending a children’s outpatient clinic to complete a brief questionnaire that was interspersed with educational content to rectify any knowledge gaps. A total of 396 parents (of 414 approached) agreed to participate. There were gaps in parental knowledge, including not knowing where the appendix is located (one-third of respondents), not knowing what appendicitis is (40% of respondents), and underestimating the incidence of appendicitis. Parents typically overestimated the risks of complications and dying from both uncomplicated and complicated appendicitis. There was no influence of gender, age, or previous experience of appendicitis on these findings. When presented with the scenario of equal effectiveness of non-operative treatment and surgery for uncomplicated appendicitis, 59% of respondents expressed a preference for non-operative treatment over surgery, while 21% expressed a preference for surgery (20% expressed no preference). These findings are important for clinicians and researchers when discussing appendicitis and treatment options with families, and justify ongoing research into the comparative effectiveness of non-operative treatment and surgery.
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Theodorou CM, Lee SY, Lawrence Y, Saadai P, Hirose S, Brown EG. The Utility of Discharge Antibiotics in Pediatric Perforated Appendicitis Without Leukocytosis. J Surg Res 2022; 275:48-55. [PMID: 35219251 PMCID: PMC10032146 DOI: 10.1016/j.jss.2022.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/14/2021] [Accepted: 01/26/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Optimal management of pediatric perforated appendicitis remains a topic of active investigation. Our institutional clinical practice guidelines (CPGs) were modified to discontinue antibiotics on discharge for patients with normal white blood cell count (WBC) without left shift. We hypothesized that patients would receive fewer antibiotics without increased complications. METHODS Patients <18 y old with perforated appendicitis who underwent laparoscopic appendectomy between November 1, 2016 and May 31, 2021 at a tertiary care children's hospital were included. Primary outcome was adverse events: postdischarge surgical site infection (SSI), 30-day emergency department (ED) visits, or readmissions. Outcomes were compared before and after CPG modification. Multivariable regression was performed to identify factors associated with SSI. RESULTS There were 113 patients pre- and 97 patients post-CPG modification. 23.1% of patients in the pre-cohort had an elevated discharge WBC or left shift compared to 18.9% of patients in the post-cohort (P = 0.48). Significantly fewer patients were prescribed antibiotics on discharge in the post-cohort (70.8% pre versus 14.4% post, P < 0.0001) and for fewer days (2 pre versus 0 post, P < 0.0001). Total antibiotic days decreased significantly (6.1 pre versus 4.6 post, P < 0.0001). There was an increase in postdischarge SSIs on univariate analysis (1.8% pre versus 9.3% post, P = 0.03), ED visits (9.7% pre versus 19.6% post, P = 0.04), and readmissions (5.3% pre versus 11.3% post, P = 0.13). On multivariable analysis, being in the post-cohort was not significantly associated with post-discharge SSIs after adjusting for sex, symptom duration, initial WBC, and discharge antibiotic duration (OR 0.25, 95% CI 0.04-1.4, P = 0.11). CONCLUSIONS Modification of a pediatric perforated appendicitis clinical practice guideline to discontinue antibiotics on discharge with a normal WBC without left shift was effective in decreasing antibiotic duration. This was associated with an increase in SSIs on univariate analysis, which did not persist on multivariable analysis and requires further investigation.
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Affiliation(s)
- Christina M Theodorou
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California.
| | - Su Yeon Lee
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Yemi Lawrence
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Payam Saadai
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Shinjiro Hirose
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Erin G Brown
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
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van Coller R, Arnold M, le Roux H, Tootla H, Dix-Peek S, Nuttal J, Hidarah AB, de Klerk O, Solwa A, English N, Ismail T, Bangani K, Schroeder H, Kaskar R, Payne M, Pretorius S, Gibson B, Cox S. Amoxycillin/Clavulanic acid monotherapy in complicated paediatric appendicitis: Good enough? J Pediatr Surg 2022; 57:1115-1118. [PMID: 35241278 DOI: 10.1016/j.jpedsurg.2022.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antibiotic choice for complicated appendicitis should be based on both microbiological effectiveness as well as ease of administration and cost especially in lower resourced settings. Data is limited on comparative morbidity outcomes for antibiotics with similar microbiological spectrum of activity. Incidence and morbidity of surgical site infection after appendectomy for complicated appendicitis was assessed after protocol change from triple antibiotic (ampicillin, gentamycin, and metronidazole) regimen to single agent (amoxycillin/clavulanic acid). METHODS Surgical site infection (SSI) rate, relook surgery rate and length of hospital stay were retrospectively compared in patients treated for acute appendicitis preceding (2014, 2015; "triple-therapy, TT") and following (2017, 2018; "single agent, SA") antibiotic protocol change. RESULTS The rate of complicated appendicitis was similar between groups; 72.6% in TT and 66% in SA (p = 0.239). Significantly, SSI occurred in 22.7% of the SA group compared to 13.3% in TT group (OR 1.920, 95% CI 1.000-3.689, p = 0.048). Use of laparoscopy increased from 31% in TT to 89% in SA, but with subgroup analysis this was not associated with increased SSI (17.3% in open and 20.6% in laparoscopic; OR 0.841, 95% CI 0.409-1.728, p = 0.637). Relook rate (OR 1.444, 95% CI 0.595-3.507, p = 0.093) length of hospital stay (U = 6859, z = -1.163, p = 0.245), and ICU admission (U = 7683, z = 0.634 p = 0.522) were equivocal. Neither group had mortalities. CONCLUSIONS Despite increased SSI with SA, overall morbidity relating to ICU admission, relook rate and length of hospital stay was similar in both groups. More prospective research is required to confirm equivalent overall morbidity and that single agent therapy is more cost-effective with acceptable clinical outcomes.
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Affiliation(s)
- Rochelle van Coller
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa.
| | - Marion Arnold
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Hettie le Roux
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Hafsah Tootla
- Division of Medical Microbiology, University of Cape Town/National Health Laboratory Service, (Microbiology), Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Stewart Dix-Peek
- Division of Orthopedic Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - James Nuttal
- Division of Medical Microbiology, University of Cape Town/National Health Laboratory Service, (Microbiology), Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Abdullah Bin Hidarah
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Olivia de Klerk
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Aneesa Solwa
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Nathan English
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Tasneem Ismail
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Kolosa Bangani
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Haneem Schroeder
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Razeena Kaskar
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Matthew Payne
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Stefan Pretorius
- Pharmacy, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Brittany Gibson
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
| | - Sharon Cox
- Division of Paediatric Surgery, University of Cape Town/ Red Cross War Memorial Children's Hospital, Cape Town, Western Cape, South Africa
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Worden LJ, Dumkow LE, VanLangen KM, Beuschel TS, Jameson AP. Antipseudomonal Versus Narrow-Spectrum Agents for the Treatment of Community-Onset Intra-abdominal Infections. Open Forum Infect Dis 2021; 8:ofab514. [PMID: 34859114 PMCID: PMC8633768 DOI: 10.1093/ofid/ofab514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background Antipseudomonal antibiotics are often used to treat community-acquired intra-abdominal infections (CA-IAIs) despite common causative pathogens being susceptible to more narrow-spectrum agents. The purpose of this study was to compare treatment-associated complications in adult patients treated for CA-IAI with antipseudomonal versus narrow-spectrum regimens. Methods This retrospective cohort study included patients >18 years admitted for CA-IAI treated with antibiotics. The primary objective of this study was to compare 90-day treatment-associated complications between patients treated empirically with antipseudomonal versus narrow-spectrum regimens. Secondary objectives were to compare infection and treatment characteristics along with patient outcomes. Subgroup analyses were planned to compare outcomes of patients with low-risk and high-risk CA-IAIs and patients requiring surgical intervention versus medically managed. Results A total of 350 patients were included: antipseudomonal, n=204; narrow spectrum, n=146. There were no differences in 90-day treatment-associated complications between groups (antipseudomonal 15.1% vs narrow spectrum 11.3%, P=.296). In addition, no differences were observed in hospital length of stay, 90-day readmission, Clostridiodes difficile, or mortality. In multivariate logistic regression, treatment with a narrow-spectrum regimen (odds ratio [OR], 0.75; 95% confidence interval, 0.39–1.45) was not independently associated with the primary outcome. No differences were observed in 90-day treatment-associated complications for (1) patients with low-risk (antipseudomonal 15% vs narrow spectrum 9.6%, P=.154) or high-risk CA-IAI (antipseudomonal 15.8% vs narrow spectrum 22.2%, P=.588) or (2) those who were surgically (antipseudomonal 8.5% vs narrow spectrum 9.2%, P=.877) or medically managed (antipseudomonal 23.1 vs narrow spectrum 14.5, P=.178). Conclusions Treatment-associated complications were similar among patients treated with antipseudomonal and narrow-spectrum antibiotics. Antipseudomonal therapy is likely unnecessary for most patients with CA-IAI.
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Affiliation(s)
- Lacy J Worden
- Mercy Health Saint Mary's, Department of Pharmacy, Grand Rapids, Michigan, USA
| | - Lisa E Dumkow
- Mercy Health Saint Mary's, Department of Pharmacy, Grand Rapids, Michigan, USA.,Mercy Health Saint Mary's, Division of Infectious Diseases, Grand Rapids, Michigan, USA
| | - Kali M VanLangen
- Mercy Health Saint Mary's, Department of Pharmacy, Grand Rapids, Michigan, USA.,Ferris State University, College of Pharmacy, Big Rapids, Michigan, USA
| | - Thomas S Beuschel
- Mercy Health Saint Mary's, Department of Pharmacy, Grand Rapids, Michigan, USA
| | - Andrew P Jameson
- Mercy Health Saint Mary's, Department of Pharmacy, Grand Rapids, Michigan, USA.,Mercy Health Saint Mary's, Division of Infectious Diseases, Grand Rapids, Michigan, USA.,Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
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13
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Theodorou CM, Stokes SC, Hegazi MS, Brown EG, Saadai P. Is Pseudomonas infection associated with worse outcomes in pediatric perforated appendicitis? J Pediatr Surg 2021; 56:1826-1830. [PMID: 33223225 PMCID: PMC8096855 DOI: 10.1016/j.jpedsurg.2020.10.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/11/2020] [Accepted: 10/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is little information on the effects of Pseudomonas infection on outcomes in perforated appendicitis. As Pseudomonas is not covered by many empiric appendicitis antibiotic regiments, we hypothesized that children with Pseudomonas would have worse outcomes. METHODS Patients <18 years old undergoing appendectomy for perforated appendicitis at a tertiary children's hospital 2015-2019 were included and were stratified by presence of Pseudomonas on intraoperative culture. The primary outcome was post-operative organ-space infection (SSI). RESULTS Intraoperative cultures were collected in 58.4% of patients (n = 149/255) with 22.2% (n = 33) positive for Pseudomonas. SSIs occurred in 21.2% of children with Pseudomonas compared to 20.7% of children without Pseudomonas (p = 0.9). Children with Pseudomonas had longer antibiotic duration (9.1 vs. 6.7 days, p = 0.03) and LOS (6.7 vs. 5.9 days, p = 0.03) than those without, but a similar rate of post-operative interventions (12.2% vs. 19.0%, p = 0.4), hospital costs ($28,860 vs. $23,945, p = 0.3), ED visits (9.1% vs. 19.9%, p = 0.3), and readmissions (9.1% vs. 9.5%, p = 1). CONCLUSION Pseudomonas was identified in 22% children with perforated appendicitis and was associated with longer antibiotic durations and LOS, but similar rates of SSI, post-operative interventions, and readmissions compared to children without Pseudomonas. Empiric coverage of Pseudomonas may not be necessary.
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Affiliation(s)
- Christina M Theodorou
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA.
| | - Sarah C Stokes
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
| | - Mennatalla S Hegazi
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
| | - Erin G Brown
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
| | - Payam Saadai
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
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Kwok CPD, Tsui SYB, Chan KWE. Updates on bacterial resistance and empirical antibiotics treatment of complicated acute appendicitis in children. J Pediatr Surg 2021; 56:1145-1149. [PMID: 33845984 DOI: 10.1016/j.jpedsurg.2021.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Through historical comparison with our previous study published 10 years ago, this paper aims to provide latest analysis of local bacteriology of acute complicated appendicitis and evaluate the effects of early escalation of potent antibiotics on course of postoperative recovery. METHODS A 5-year retrospective review of all children receiving emergency laparoscopic appendicectomies for acute appendicitis from December 2014 to November 2019 was conducted. RESULTS 257 cases of acute appendicitis were included, 126 were complicated appendicitis (38 gangrenous, 88 ruptured). 96 had positive peritoneal swab culture, 53 (42.1%) grew resistant bacterial strains, including extended spectrum beta-lactamase producing E. coli (ESBL E. coli), Pseudomonas aeruginosa, against traditional empirical triple antibiotics. The prevalence had significantly increased over the past decade (p = 0.008). In our patients, piperacillin/tazobactam, ertapenem, gentamicin provided coverage of 69.8%, 45.3% and 45.3% respectively. For patients with early escalation of postoperative antibiotics, no statistical significance was identified in terms of postoperative complications (p = 0.883), or duration of antibiotics (p = 0.0615). CONCLUSION Growing prevalence of resistant strains were observed over the decade. Piperacillin/tazobactam provided the best coverage (69.8%) against resistant bacterial strains in our patients. Early escalation of antibiotics failed to reduce postoperative complications and antibiotics duration. TYPE OF STUDY Clinical Research, Retrospective Historical Comparative Study Level of Evidence: Level III.
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Affiliation(s)
- Chun Pong Daniel Kwok
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong.
| | - Siu Yan Bess Tsui
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Kin Wai Edwin Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
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15
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IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy. Ann Surg 2021; 274:406-410. [PMID: 34132703 DOI: 10.1097/sla.0000000000005006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. METHODS A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. RESULTS One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. CONCLUSIONS In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.
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16
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Ferguson DM, Anderson KT, Arshad SA, Garcia EI, Hebballi NB, Li LT, Kawaguchi AL, Lally KP, Tsao K. Prophylactic intraabdominal drains do not confer benefit in pediatric perforated appendicitis: Results from a quality improvement initiative. J Pediatr Surg 2021; 56:727-732. [PMID: 32709531 DOI: 10.1016/j.jpedsurg.2020.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/29/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis. METHODS A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed. RESULTS Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment. CONCLUSIONS A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - K Tinsley Anderson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Elisa I Garcia
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Nutan B Hebballi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Linda T Li
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States.
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Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols. J Pediatr Surg 2021; 56:663-667. [PMID: 33183744 DOI: 10.1016/j.jpedsurg.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis. MATERIAL AND METHODS A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant. RESULTS A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation. CONCLUSION Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted. LEVELS OF EVIDENCE Therapeutic study; Level 3.
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Ketha B, Stephenson KJ, Dassinger MS, Smith SD, Burford JM. Eliminating Use of Home Oral Antibiotics in Pediatric Complicated Appendicitis. J Surg Res 2021; 263:151-154. [PMID: 33652177 DOI: 10.1016/j.jss.2020.12.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 12/15/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Postoperative oral antibiotic management at discharge for perforated appendicitis varies by institution. A prior study at our institution led to a decrease in antibiotic therapy in patients without leukocytosis. A subsequent protocol change eliminated the white blood cell count check and oral antibiotics if discharge criteria were met by postoperative day seven. We hypothesized this change could be made without an increase in abscess or readmission rates. METHODS We conducted a retrospective review of patients with perforated appendicitis over two 1-year periods after institutional review board approval (262061). In the pre-protocol group, a white blood cell count was checked at discharge and patients with leukocytosis were prescribed oral antibiotics to complete a total of 7 d. In the post-protocol group, no white blood cell count was checked and patients were discharged home without antibiotics. RESULTS There were a total of 174 patients with complicated appendicitis in the two 1-year periods with 129 (74%) patients with perforated appendicitis discharged before postoperative day seven. The pre-protocol group included 71 children, and post-protocol included 58 children. There were no differences between mean postoperative days to discharge (2.57 versus 3, P = 0.0896), postoperative abscess rate (12.7% versus 12.1%, P = 1.0000), or readmission rate (12.7% versus 17.2%, P = 0.6184). None of the patients in the post-protocol group were discharged home with oral antibiotics compared with 22.5% in the pre-protocol group (P < 0.001). CONCLUSIONS For pediatric patients with perforated appendicitis discharged before postoperative day seven, stopping antibiotics at the time of discharge significantly decreased our home antibiotic use without an increase in postoperative morbidity.
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Affiliation(s)
- Bavana Ketha
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas.
| | - Krista J Stephenson
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
| | - Melvin S Dassinger
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
| | - Samuel D Smith
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
| | - Jeffrey M Burford
- Arkansas Children's Hospital, Division of Pediatric Surgery, Little Rock, Arkansas
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Hall NJ, Sherratt FC, Eaton S, Reading I, Walker E, Chorozoglou M, Beasant L, Wood W, Stanton M, Corbett HJ, Rex D, Hutchings N, Dixon E, Grist S, Hoff WV, Crawley E, Blazeby J, Young B. Conservative treatment for uncomplicated appendicitis in children: the CONTRACT feasibility study, including feasibility RCT. Health Technol Assess 2021; 25:1-192. [PMID: 33630732 PMCID: PMC7958256 DOI: 10.3310/hta25100] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking. OBJECTIVES The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children. DESIGN This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set. SETTING This study was set in three specialist NHS paediatric surgical units in England. PARTICIPANTS Children (aged 4-15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set. INTERVENTIONS Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy. MAIN OUTCOME MEASURES The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial. DATA SOURCES Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews. RESULTS Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol. LIMITATIONS Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time. CONCLUSIONS A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres. FUTURE WORK Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved. TRIAL REGISTRATION Current Controlled Trials ISRCTN15830435. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nigel J Hall
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Frances C Sherratt
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Simon Eaton
- University College London Great Ormond Street Institute of Child Health, Department of Population Health Sciences, University College London, London, UK
| | - Isabel Reading
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Erin Walker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessment Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lucy Beasant
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Wendy Wood
- National Institute for Health Research (NIHR), Research Design Service South Central, University of Southampton, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Harriet J Corbett
- Department of Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Dean Rex
- Department of Paediatric Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Natalie Hutchings
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Elizabeth Dixon
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Simon Grist
- Patient and public involvement representative
| | - William Van't Hoff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Esther Crawley
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bridget Young
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
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20
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Seddik TB, Rabsatt LA, Mueller C, Bassett HK, Contopoulos-Ioannidis D, Bio LL, Anderson VD, Schwenk HT. Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis. J Surg Res 2020; 260:141-148. [PMID: 33340867 DOI: 10.1016/j.jss.2020.11.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/05/2020] [Accepted: 11/15/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis. METHODS This is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared. RESULTS Forty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively. CONCLUSIONS Provider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.
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Affiliation(s)
- Talal B Seddik
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California.
| | - Lauren A Rabsatt
- Analytics and Clinical Effectiveness Specialist, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Claudia Mueller
- Pediatric Surgery, Stanford University School of Medicine, Stanford, California
| | - Hannah K Bassett
- Pediatric Hospitalist Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Victor D Anderson
- Infection Prevention and Control Specialist, Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Hayden T Schwenk
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California
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21
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A Standardized Protocol for the Management of Appendicitis in Children Reduces Resource Utilization. Pediatr Qual Saf 2020; 5:e357. [PMID: 33134759 PMCID: PMC7591119 DOI: 10.1097/pq9.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022] Open
Abstract
Appendicitis is the most common condition requiring emergency surgery in children. We implemented a standardized protocol (SP) for treating children with appendicitis to provide more uniform care and reduce resource utilization.
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22
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Son JT, Lee GC, Kim HO, Kim T, Lee D, Lee SR, Jung KU, Kim H, Chun HK. Routine Intraoperative Bacterial Culture May Be Needed in Complicated Appendicitis. Ann Coloproctol 2020; 36:155-162. [PMID: 32674546 PMCID: PMC7392572 DOI: 10.3393/ac.2019.11.04.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/04/2019] [Indexed: 11/09/2022] Open
Abstract
Purpose Choosing the appropriate antibiotic is important for treatment of complicated appendicitis. However, increasing multidrug resistant bacteria have been a serious problem for successful treatment. This study was designed to identify bacteria isolated from patients with complicated appendicitis and reveal their susceptibilities for antibiotics and their relationship with patient clinical course. Methods This study included patients diagnosed with complicated appendicitis and examined the bacterial cultures and antimicrobial susceptibilities of the isolates. Data were retrospectively collected from medical records of Kangbuk Samsung Hospital from January 2008 to February 2018. Results The common bacterial species cultured in complicated appendicitis were as follows: Escherichia coli (n=113, 48.9%), Streptococcus spp. (n=29, 12.6%), Pseudomonas spp. (n=23, 10.0%), Bacteriodes spp. (n=22, 9.5%), Klebsiella (n=11, 4.8%), and Enterococcus spp. (n=8, 3.5%). In antibiotics susceptibility testing, the positive rate of extended-spectrum beta lactamase (ESBL) was 9.1% (21 of 231). The resistance rate to carbapenem was 1.7% (4 of 231), while that to vancomycin was 0.4% (1 of 231). E. coli was 16.8% ESBL positive (19 of 113) and had 22.1% and 19.5% resistance rates to cefotaxime and ceftazidime, respectively. Inappropriate empirical antibiotic treatment (IEAT) occurred in 55 cases (31.8%) and was significantly related with organ/space surgical site infection (SSI) (7 of 55, P=0.005). Conclusion The rate of antibiotic resistance organisms was high in community-acquired complicated appendicitis in Koreans. Additionally, IEAT in complicated appendicitis may lead to increased rates of SSI. Routine intraoperative culture in patients with complicated appendicitis may be an effective strategy for appropriate antibiotic regimen.
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Affiliation(s)
- Jung Tack Son
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gue Chun Lee
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Ook Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taewoon Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Donghyoun Lee
- Department of Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Sung Ryol Lee
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hungdai Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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23
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Zavras N, Vaos G. Management of complicated acute appendicitis in children: Still an existing controversy. World J Gastrointest Surg 2020; 12:129-137. [PMID: 32426092 PMCID: PMC7215970 DOI: 10.4240/wjgs.v12.i4.129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/24/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
Complicated acute appendicitis (CAA) is a serious condition and carries significant morbidity in children. A strict diagnosis is challenging, as there are many lesions that mimic CAA. The management of CAA is still controversial. There are two options for treatment: Immediate operative management and non-operative management with antibiotics and/or drainage of any abscess or phlegmon. Each method of treatment has advantages and disadvantages. Operative management may be difficult due to the presence of inflamed tissues and may lead to detrimental events. In many cases, non-operative management with or without drainage and interval appendectomy is advised. The reasons for this approach include new medications and policies for the use of antibiotic therapy. Furthermore, advances in radiological interventions may overcome difficulties such as diagnosing and managing the complications of CAA without any surgeries. However, questions have been raised about the risk of recurrence, prolonged use of antibiotics, lengthened hospital stay and delay in returning to daily activities. Moreover, the need for interval appendectomy is currently under debate because of the low risk of recurrence. Due to the paucity of high-quality studies, more randomized controlled trials to determine the precise management strategy are needed. This review aims to study the current data on operative vs non-operative management for CAA in children and to extract any useful information from the literature.
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Affiliation(s)
- Nick Zavras
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
| | - George Vaos
- Department of Paediatric Surgery, “ATTIKON” University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens 12462, Greece
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24
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Schmidt YM, Wendling-Keim D, von Schweinitz D, Hubertus J, Berger M. Prophylactic Drain Placement in Childhood Perforated Appendicitis: Does Spillage Matter? Front Pediatr 2020; 8:588109. [PMID: 33163468 PMCID: PMC7581796 DOI: 10.3389/fped.2020.588109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022] Open
Abstract
Background: Prophylactic abdominal drains for perforated appendicitis in children have generally been regarded as obsolete because several studies showed inferior results for drain placement in the past. Despite these results, prophylactic abdominal drains for perforated appendicitis remain omnipresent in pediatric surgery especially when gross spillage is observed at the time of appendectomy. Here, we hypothesize that even if accounting for gross intra-abdominal spillage, prophylactic drain placement for perforated appendicitis in children is not beneficial. Patients and Methods: The charts of all children (<18 years) who underwent an appendectomy at our institution from July 2013 to March 2020 were analyzed. The data from 65 patients who presented with perforated appendicitis were included. Patients were grouped according to the amount of intraoperative spillage. Demographics, laboratory data, operative findings, and postoperative outcomes were analyzed. Results: Of all patients, 34 were male, and 31 were female, with a mean age of 10.5 ± 3.7 years. There were no statistically significant differences between the groups for age and sex (p = 0.6985 and p = 0.6222, respectively). Prophylactic drains were placed according to the surgeon's preference in 32 children. There were no statistically significant differences between the groups in the rate of intra-abdominal abscess formation, wound infection, and bowel obstruction, regardless of the amount of spillage encountered during an appendectomy. However, independently of the amount of spillage, the length of hospital stay was longer in the children in which a drain had been placed (p = 0.0041). Conclusion: In our cohort, we could not find a benefit from drain placement even in case of gross spillage at the time of appendectomy. Rather, drain placement was associated with an increase in length of hospital stay.
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Affiliation(s)
- Yannick Michael Schmidt
- Department of Pediatric Surgery, Research Laboratories, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Danielle Wendling-Keim
- Department of Pediatric Surgery, Research Laboratories, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Dietrich von Schweinitz
- Department of Pediatric Surgery, Research Laboratories, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jochen Hubertus
- Department of Pediatric Surgery, Research Laboratories, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Michael Berger
- Department of Pediatric Surgery, Research Laboratories, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
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25
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The future of publishing. J Pediatr Surg 2019; 54:2469-2472. [PMID: 31500877 DOI: 10.1016/j.jpedsurg.2019.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 08/24/2019] [Indexed: 11/22/2022]
Abstract
This is the first Journal of Pediatric Surgery lecture at the Pacific Association of Pediatric Surgeons (PAPS) meeting.
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26
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Roque FMCB, Melo Filho AA, Roque AJCB, Roque HCB, Moreira TMM, Chaves EMC. ANTIBIOTICS FOR APPENDICECTOMY IN CHILDREN AND ADOLESCENTS DURING THE PERIOPERATIVE PERIOD: AN INTEGRATIVE REVIEW. REVISTA PAULISTA DE PEDIATRIA 2019; 37:494-502. [PMID: 31291445 PMCID: PMC6821483 DOI: 10.1590/1984-0462/;2019;37;4;00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/07/2018] [Indexed: 11/21/2022]
Abstract
ABSTRACT Objective: To analyze the preoperative use of antibiotics in children and adolescents requiring appendectomy. Data source: Integrative review was performed in the MEDLINE, Latin American and Caribbean Health Sciences (LILACS) and Cochrane databases and the PubMed portal, with no time limit. The keywords used were: appendicitis, child, adolescent and antibacterial with Boolean AND. The articles included were published in Portuguese, English or Spanish and whose participants were under 18 years of age. Review articles and guidelines were excluded. The studies were classified according to their level of evidence and 24 papers were selected. Data collection and analysis: Seven randomized clinical trial studies (level of evidence II), eight cohorts (level III), seven retrospective observational studies (level V) and two historical documentary analysis (level IV) were selected. The studies addressed antibiotics used in acute appendicitis in both uncomplicated and complicated cases. Antibiotics initiated in the preoperative period showed a decrease in the rates of surgical wound infections. First-line (empiric) regimens were tested for sensitivity to microorganisms in peritoneal material cultures, however the results were controversial. Broad-spectrum antibiotics have been suggested in some studies because they have good coverage, but in others they have not been recommended because of the risk of developing bacterial resistance. Shorter administration time and earlier change to the oral route reduced hospitalization time. Conclusions: There are several clinical protocols with different antibiotics. However, there is no standardization concerning the type of antibiotic drug, time of use, or route.
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27
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Bi LW, Yan BL, Yang QY, Cui HL. Peritoneal irrigation vs suction alone during pediatric appendectomy for perforated appendicitis: A meta-analysis. Medicine (Baltimore) 2019; 98:e18047. [PMID: 31852066 PMCID: PMC6922395 DOI: 10.1097/md.0000000000018047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There currently exists no substantial evidence reporting the efficacy of peritoneal irrigation in reducing the incidence of postoperative intra-abdominal abscess in pediatric patients. The purpose of our study was to perform a meta-analysis to compare rates of intra-abdominal abscess after appendectomy between irrigation and suction alone groups. METHODS We identified studies by a systematic search in EMBASE, PubMed, Web of Science, and the Cochrane Library to recognize randomized controlled trials and case control studies from the 1950 to May 2019. We limited the English language studies. We checked the reference list of studies to recognize other potentially qualified trials. We analyzed the merged data with use of the Review Manager 5.3. RESULTS We identified 6 eligible papers enrolling a total of 1633 participants. We found no significant difference in the incidence of postoperative intraabdominal abscess, wound infection, and the length of hospitalization between 2 group, but duration of surgery is longer in irrigation group (MD = 6.76, 95% CI = 4.64 to 8.87, P < .001; heterogeneity, I = 25%, P = .26). CONCLUSION Our meta-analysis did not provide strong evidence allowing definite conclusions to be drawn, but suggested that peritoneal irrigation during appendectomy did not decrease the incidence of postoperative IAA. This meta-analysis also indicated the need for more high-quality trials to identify methods to decrease the incidence of postoperative IAA in pediatric perforated appendicitis patients.Trial registration number Standardization of endoscopic treatment of acute abdomen in children: 14RCGFSY00150.
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Affiliation(s)
- Le-Wee Bi
- Department of the Graduate School, Tianjin Medical University
| | - Bei-Lei Yan
- Department of the Graduate School, Tianjin Medical University
| | - Qian-Yu Yang
- Department of the Graduate School, Tianjin Medical University
| | - Hua-Lei Cui
- Department of General Surgery, Tianjin Children's Hospital, Tianjin
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28
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Holguín-Sanabria DA, Perilla-López MÁ, Castañeda-Espinosa S, Jaimes-de La Hoz P, Aragón S, Valero JJ, Molina ID, Fierro-Ávila F. Prevalence of organ-space surgical site infections after appendectomy for ruptured appendix in children. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n4.64434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Appendicitis can be classified as non-perforated and perforated; based on such classification, the reported organ-space surgical site infection (OS-SSI) rate is 0.8% and 18%, respectively.Objective: To establish the prevalence of OS-SSI in patients with perforated appendicitis treated in a pediatric hospital in 2012.Materials and methods: Retrospective, observational and descriptive study conducted at Fundación Hospital Pediátrico La Misericordia, with a random sample of 200 patients, of which 160 met the inclusion criteria.Results: 20 patients (12.5%) presented with OS-SSI and all of them received antibiotic treatment; 70% did not require abscess drainage. Patients ≥8 years of age had 5 times more abscesses than younger ones (17.6% vs. 3.4%). OS-SSI was found in 33% of patients with free fecalith and in 50% of the patients who required postoperative management at the ICU vs. 9.5% of the patients who received management in the intermediate care unit and the inpatient hospital floors. The total rate of surgical site infection was 24.3% (11.8% superficial, 0% deep and 12.5% organ-space).Conclusions: The prevalence of OS-SSI found here is lower than what has been reported in the literature. Being 8 years or older and having free fecalith are risk factors to develop this type of infection. The higher frequency of OS-SSI in patients treated at the ICU during the post-operative period observed here suggests that this condition may be associated with septic shock.
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29
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Child J, Chen X, Mistry RD, Somme S, MacBrayne C, Anderson PL, Jones RN, Parker SK. Pharmacokinetic and Pharmacodynamic Properties of Metronidazole in Pediatric Patients With Acute Appendicitis: A Prospective Study. J Pediatric Infect Dis Soc 2019; 8:297-302. [PMID: 29788329 DOI: 10.1093/jpids/piy040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 04/24/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND Metronidazole is traditionally dosed every 6-8 hours even though in adults it has a long half-life, concentration-dependent killing, and 3-hour postantibiotic effect. Based on this logic, some pediatric hospitals adopted once-daily dosing for appendicitis, despite limited pharmacokinetics-pharmacodynamics (PK/PD) in children. We studied pediatric patients with appendicitis given metronidazole once daily to determine whether this dosing would meet target area under the curve (AUC)/minimum inhibitory concentration (MIC) ratio of ≥70 for Bacteroides fragilis. METHODS One hundred pediatric patients aged 4-17 years had an average of 3 blood draws per patient during the first 24 hours after a 30 mg/kg per dose of intravenous metronidazole. Concentrations of drug were determined using validated liquid chromatography and tandem mass spectrometry. A NONMEM model was constructed for determining PK, followed by Monte Carlo simulations to generate a population of plasma concentration-time AUC of metronidazole and hydroxy-metronidazole. RESULTS Simulated AUC values met target attainment (AUC/MIC ratio of ≥70 to B fragilis MICs) for 96%-100% of all patients for an MIC of 2 mcg/mL. For MICs of 4 and 8 mcg/mL, target attainment ranged from 61% to 97% and 9% to 71%, respectively. Areas under the curve were similar to that of adults receiving 1000 mg and 1500 mg q24, or 500 mg q8 hours. CONCLUSIONS Metronidazole, 30 mg/kg per dose, once daily achieved AUC target attainment for B fragilis with an MIC of 2 mcg/mL or less in pediatric appendicitis patients. Based on this and studies in adults, there does not seem to be any PK/PD advantage of more frequent dosing in this population.
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Affiliation(s)
- Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Xinhui Chen
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Stig Somme
- Division of General, Thoracic, and Fetal Pediatric Surgery, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Christine MacBrayne
- Department of Pharmacy, Children's Hospital Colorado, Aurora.,University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | - Peter L Anderson
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | | | - Sarah K Parker
- Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, Aurora
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30
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Bonasso PC, Dassinger MS, Wyrick DL, Smith SD, Burford JM. Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis. Am J Surg 2019; 217:1099-1101. [PMID: 30639131 DOI: 10.1016/j.amjsurg.2018.12.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
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31
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Do‐Wyeld M, Rogerson T, Court‐Kowalski S, Cundy TP, Khurana S. Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care. ANZ J Surg 2019; 89:1379-1385. [PMID: 30989778 DOI: 10.1111/ans.15125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/08/2019] [Accepted: 01/25/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Montgommery Do‐Wyeld
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Thomas Rogerson
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
| | - Stefan Court‐Kowalski
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Thomas P. Cundy
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
| | - Sanjeev Khurana
- Department of Paediatric SurgeryWomen's and Children's Hospital Adelaide South Australia Australia
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Nordin AB, Diefenbach K, Sales SP, Christensen J, Besner GE, Kenney BD. Gangrenous appendicitis: No longer complicated. J Pediatr Surg 2019; 54:718-722. [PMID: 30551843 DOI: 10.1016/j.jpedsurg.2018.10.064] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 10/10/2018] [Accepted: 10/21/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections. METHODS In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS, presence of a postoperative infection, and 30-day readmissions. RESULTS Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2. Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p < 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses. CONCLUSIONS Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postoperative infections or readmissions. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Andrew B Nordin
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; State University of New York University at Buffalo, Department of General Surgery, 100 High St, Buffalo, NY 14203.
| | - Karen Diefenbach
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210.
| | - Stephen P Sales
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205.
| | - Jeff Christensen
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205.
| | - Gail E Besner
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210.
| | - Brian D Kenney
- Nationwide Children's Hospital, Department of Pediatric Surgery, 700 Children's Drive, Columbus, OH, 43205; The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210.
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Hamdy RF, Handy LK, Spyridakis E, Dona D, Bryan M, Collins JL, Gerber JS. Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated Appendicitis in Children. Surg Infect (Larchmt) 2019; 20:399-405. [PMID: 30874482 DOI: 10.1089/sur.2018.234] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. The antibiotic choice differs widely across children's hospitals, and the optimal regimen for perforated appendicitis remains unclear. Methods: We conducted a retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large tertiary-care children's hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes with confirmation by chart review. Patients were excluded if they had been admitted ≥48 hours prior to diagnosis, had a history of appendicitis, received inotropic agents, were immunocompromised, or were given an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an anti-pseudomonal drug (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days after diagnosis. The primary outcome of interest was post-operative complications, defined as development of an incisional infection or abscess within six weeks of hospital discharge. Results: Of the 353 children who met the inclusion criteria, 252 (71%) received CTX/MTZ and the others received an anti-pseudomonal regimen. A post-operative complication occurred in 37 (14.7%) of the CTX/MTZ group versus 18 (17.8%) of the anti-pseudomonal group. Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on anti-pseudomonal antibiotics (p = 0.32). In a multivariable logistic regression model adjusting for sex, age, ethnicity, and duration of symptoms prior to presentation, the adjusted odds ratio for post-operative complications in children receiving anti-pseudomonal antibiotics was 1.25 (95% confidence interval 0.66-2.40). Conclusion: Post-operative complication rates did not differ for children treated with CTX/MTZ versus a broader-spectrum regimen.
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Affiliation(s)
- Rana F Hamdy
- 1 Department of Pediatrics, Children's National Health System, Washington, DC
| | - Lori K Handy
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evangelos Spyridakis
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniele Dona
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Bryan
- 3 Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia
| | - Joy L Collins
- 4 Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Efficacy of oral antibiotics in children with post-operative abscess from perforated appendicitis. Pediatr Surg Int 2019; 35:329-333. [PMID: 30506487 DOI: 10.1007/s00383-018-4424-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). Typically, intravenous antibiotics by a peripherally inserted venous catheter are utilized to treat the abscess. We sought to evaluate the role of oral antibiotics in this population. METHODS This is a retrospective review conducted of children between January 2005 and September 2015 with a PIAA. Demographics, clinical course, complications, and follow-up were analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral vs IV antibiotics after diagnosis of PIAA. RESULTS 103 children were included. Days of symptoms prior to admission were 3.2 ± 2.3 days with a WBC of 17.9 ± 6.4. Median time to diagnosis of PIAA from appendectomy was 7 days (7, 10). Mean total length of stay was 10 ± 3.4 days. 42% were treated with oral antibiotics (n = 43) versus 58% IV antibiotics (n = 60) at the time of discharge. We found a significant increase in total length of hospital stay (9.1 vs 10.7, p = 0.02) and number of medical encounters required for treatment (3.4 vs 4.4, p ≤ 0.01) in the IV group. CONCLUSIONS PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivalent outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required.
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Arnold MR, Wormer BA, Kao AM, Klima DA, Colavita PD, Cosper GH, Heniford BT, Schulman AM. Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial. Pediatr Surg Int 2018; 34:1257-1268. [PMID: 30218170 DOI: 10.1007/s00383-018-4343-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis. METHODS This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared. RESULTS Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001). CONCLUSION Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.
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Affiliation(s)
- Michael R Arnold
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Blair A Wormer
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Angela M Kao
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - David A Klima
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Paul D Colavita
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Graham H Cosper
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA.,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA.,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA
| | - Brant Todd Heniford
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Andrew M Schulman
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA. .,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA. .,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA.
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Abstract
BACKGROUND Complicated appendicitis, characterized by perforation and/or peritonitis, is common in children, and late infectious complications are frequent. The best antibiotic treatment approach is unknown, resulting in substantial variation in care. We evaluated the effects of 2 successive interventions, an antimicrobial stewardship program (ASP) and a condition-specific clinical practice guideline (CPG), on antimicrobial utilization and patient outcomes in these patients. METHODS The ASP at our institution was begun in March 2012. The CPG, a standardized antibiotic treatment, was implemented in July 2013. We reviewed every case of complicated appendicitis managed with early appendectomy between January 2011 and October 2014. Patients were thus divided into 3 eras based on their exposure to the following: (1) neither intervention, (2) ASP only or (3) both ASP and CPG. We compared measures of antibiotic utilization and clinical outcomes among the 3 eras. RESULTS A total of 313 patients were included in the study: 91 exposed to neither intervention; 100 exposed to only the ASP; and 122 exposed to both interventions. With ASP implementation, there were declines in the use of unnecessarily broad or toxic antibiotic regimens. With CPG implementation, there was a decrease in total antibiotic utilization and discharges with intravenous antibiotics. Compliance with CPG-recommended antibiotics exceeded 90%. There was no significant change in overall adverse events; there was a decline in the incidence of surgical-site infections in patients exposed to both interventions. CONCLUSIONS Complicated appendicitis is an important target for antimicrobial stewardship and quality improvement efforts. A condition-specific CPG can improve both antimicrobial utilization and clinical outcomes.
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Taleb M, Nardi N, Arnaud A, Costet N, Donnio PY, Engrand C, Habonimana E, Wodey E, Tattevin P. Simplification of first-line antibacterial regimen for complicated appendicitis in children is associated with better adherence to guidelines and reduced use of antibiotics. Int J Antimicrob Agents 2018; 52:293-296. [PMID: 29678565 DOI: 10.1016/j.ijantimicag.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 04/01/2018] [Accepted: 04/09/2018] [Indexed: 01/25/2023]
Abstract
Acute appendicitis in children requires early surgery and short-course antibiotics active against Enterobacteriaceae and anaerobes. Although an aminoglycoside-containing three-drug regimen has been used successfully for decades, simpler regimens with similar efficacy are increasingly used. This study evaluated the impact of a switch from the combination of cefotaxime, metronidazole and gentamicin (regimen 1) to piperacillin/tazobactam (regimen 2) as first-line regimen for complicated acute appendicitis in children. In total, 171 children were enrolled [median (IQR) age, 10 (6-13) years], treated with regimen 1 (n = 80) or regimen 2 (n = 91) following surgery for complicated acute appendicitis. The two groups were comparable except for surgical approach (through laparoscopy in 46% vs. 88% for regimens 1 and 2, respectively; P < 0.001). Post-operative complications and duration of hospital stay were similar. Deviations from antibacterial treatment protocol decreased from 36% (29/80) to 14% (13/91) (P < 0.001), with a dramatic reduction in antibacterial treatment duration from median (IQR) of 15 (12-16) days to 5 (5-8) days (P < 0.001). Post-operative intra-abdominal abscess developed in 32 children (18.7%). Female sex (OR = 2.76, 95% CI 1.18-6.48; P = 0.02) and sepsis/septic shock on admission (OR = 4.72, 95% CI 1.12-19.97; P = 0.035) were independently associated with post-operative intra-abdominal abscess, but not antibacterial regimen. This study shows that simplification of first-line antibacterial regimen for complicated appendicitis in children was associated with reduced protocol deviation, reduced duration of antibiotics, and similar outcomes (post-operative complications and duration of hospital stay).
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Affiliation(s)
- Marion Taleb
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Nicolas Nardi
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Alexis Arnaud
- Department of Pediatric Surgery, Rennes University Hospital, Rennes, France
| | - Nathalie Costet
- Department of Biostatistics UMR Inserm 1099 LTSI Rennes 1 University, Rennes, France
| | - Pierre-Yves Donnio
- Department of Infection Control and Prevention, Rennes University Hospital, Rennes, France
| | - Charlotte Engrand
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Edouard Habonimana
- Department of Pediatric Surgery, Rennes University Hospital, Rennes, France
| | - Eric Wodey
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Rennes University Hospital, Rennes, France.
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Hutchings N, Wood W, Reading I, Walker E, Blazeby JM, van’t Hoff W, Young B, Crawley EM, Eaton S, Chorozoglou M, Sherratt FC, Beasant L, Corbett H, Stanton MP, Grist S, Dixon E, Hall NJ. CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial. Trials 2018; 19:153. [PMID: 29499722 PMCID: PMC5833142 DOI: 10.1186/s13063-018-2520-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 02/02/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial. METHODS/DESIGN The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery. DISCUSSION In this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design. TRIAL REGISTRATION ISRCTN15830435 . Registered on 8 February 2017.
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Affiliation(s)
- Natalie Hutchings
- Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Wendy Wood
- National Institute of Health Research (NIHR), Research Design Service South Central, University of Southampton, Southampton, UK
| | - Isabel Reading
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Erin Walker
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jane M. Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - William van’t Hoff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Bridget Young
- Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Esther M. Crawley
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Simon Eaton
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Maria Chorozoglou
- Southampton Health Technology Assessment Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Frances C. Sherratt
- Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Lucy Beasant
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Harriet Corbett
- Department of Paediatric Surgery, Alder Hey Children’s NHS Foundation Trust, East Prescott Road, Liverpool, L14 5AB UK
| | - Michael P. Stanton
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Simon Grist
- Patient and Public Involvement Representative, Southampton, UK
| | - Elizabeth Dixon
- Southampton Clinical Trials Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nigel J. Hall
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University Surgery Unit, Faculty of Medicine, University of Southampton, Mailpoint 816, Tremona Road, Southampton, SO16 6YD UK
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Poola AS, Oyetunji TA, Holcomb GW, St Peter SD. Maturation of effect size during enrollment of prospective randomized trials. J Surg Res 2018; 223:34-38. [DOI: 10.1016/j.jss.2017.06.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/17/2017] [Accepted: 06/19/2017] [Indexed: 11/26/2022]
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Loftus TJ, Brakenridge SC, Croft CA, Stephen Smith R, Efron PA, Moore FA, Mohr AM, Jordan JR. Successful nonoperative management of uncomplicated appendicitis: predictors and outcomes. J Surg Res 2017; 222:212-218.e2. [PMID: 29146455 DOI: 10.1016/j.jss.2017.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 08/27/2017] [Accepted: 10/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Our objective was to identify predictors of successful nonoperative management (NOM) of uncomplicated appendicitis. We hypothesized that the absence of diabetes, absence of an appendicolith, short duration of symptoms, absence of systemic inflammation, and low modified Alvarado score would predict successful NOM. METHODS We performed a retrospective cohort analysis of 81 consecutive patients who underwent NOM of uncomplicated appendicitis. Successful NOM was defined as resolution of appendicitis with antibiotics alone and no recurrent appendicitis within 180 days. Patients with successful NOM (n = 36) were compared with patients who failed NOM (n = 45). Multivariable logistic regression was used to identify predictors of successful NOM, expressed as odds ratios (ORs) with 95% confidence intervals. Model strength was assessed by calculating area under the receiver operating characteristic curve (AUC). RESULTS Patient age (35 years), the American Society of Anesthesiologists class (2.0), and Charlson comorbidity index (0.0) were similar between groups. Independent predictors of successful NOM were duration of symptoms prior to admission >25 hours: OR 4.17 (1.42-12.24), maximum temperature within 6 hours of admission <37.3°C: OR 8.07 (1.79-36.38), modified Alvarado score <4: OR 9.06 (1.26-64.93), and appendiceal diameter <13 mm: OR 17.55 (1.30-237.28); model AUC: 0.81 (0.72-0.90). CONCLUSIONS Patients with a longer duration of symptoms prior to admission were more likely to have successful NOM. Other independent predictors of successful NOM included lower temperature, lower modified Alvarado score, and smaller appendiceal diameter. These findings provide a framework for clinical decision-making and large-scale derivation and validation of a model to predict successful NOM of uncomplicated appendicitis.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Scott C Brakenridge
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Chasen A Croft
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida
| | - R Stephen Smith
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida
| | - Philip A Efron
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Frederick A Moore
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; University of Florida Sepsis and Critical Illness Research Center, Gainesville, Florida
| | - Janeen R Jordan
- Department of Surgery in Gainesville, University of Florida Health, Gainesville, Florida; Orange Park Medical Center in Jacksonville, Orange Park, Florida.
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Shang Q, Geng Q, Zhang X, Guo C. The efficacy of combined therapy with metronidazole and broad-spectrum antibiotics on postoperative outcomes for pediatric patients with perforated appendicitis. Medicine (Baltimore) 2017; 96:e8849. [PMID: 29381994 PMCID: PMC5708993 DOI: 10.1097/md.0000000000008849] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to evaluate the efficacy of combined therapy with metronidazole and broad-spectrum antibiotics for patients with perforated appendicitis who underwent surgical intervention.Broad-spectrum antibiotic therapy is warranted in the treatment of perforated appendicitis. Metronidazole has been used as anaerobic antimicrobial therapy. However, few studies about the use of metronidazole in perforated appendicitis have been reported.The medical records of 249 patients treated with metronidazole combined with broad-spectrum antibiotics following perforated appendicitis surgery were reviewed retrospectively and compared with the medical records of 149 patients treated only with broad-spectrum antibiotics. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including postoperative complications and length of hospital stay, were compared between the 2 groups.No differences were found between the use of combined therapy with metronidazole and the use of solely broad-spectrum antibiotic agents with regard to postoperative duration of intravenous antibiotic treatment (6.8 ± 1.3 vs 7.9 ± 2.1 days, respectively, P = .18), inflammation variables at POD 5 (white blood cell [WBC] [risk ratio [RR], 1.06; 95% confidence interval [CI], 0.67-1.93, P = .15] and C-reactive protein [CRP] [RR, 1.18; 95% CI, 0.73-2.25, P = .36]) (Table 2), and the mean postoperative length of hospital stay (LOS) (RR, 0.68, 95% CI, 0.41-0.94, P = .41). There were also no differences in the incidence of postoperative complications, including the intra-abdominal or pelvic abscess rate (7[7.1%] vs 9[9.2%], respectively, P = .40), the incidence of wound infection (14[14.3%] vs 15[15.3%], respectively, P = .50), and the 30-day readmission rate (9[9.2%] vs 12[12.2%], respectively, P = .32).Regarding overall postoperative outcomes and complications, our study demonstrated no beneficial clinical effects of metronidazole administration in patients with perforated appendicitis who underwent surgical intervention. Therefore, metronidazole is not indicated when broad-spectrum antibiotics such as aminopenicillins with β-lactam inhibitors or carbapenems and select cephalosporins are used.
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Affiliation(s)
- Qingjuan Shang
- Department of Pathology, Linyi People's Hospital, Linyi, Shandong Province
| | - Qiankun Geng
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing
| | - Xuebing Zhang
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing
| | - Chunbao Guo
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
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Pini N, Pfeifle VA, Kym U, Keck S, Galati V, Holland-Cunz S, Gros SJ. Water permeability is a measure of severity in acute appendicitis. J Enzyme Inhib Med Chem 2017; 32:1036-1041. [PMID: 28762291 PMCID: PMC6009912 DOI: 10.1080/14756366.2017.1347167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Acute appendicitis is the most common indication for pediatric abdominal emergency surgery. Determination of the severity of appendicitis on clinical grounds is challenging. Complicated appendicitis presenting with perforation, abscess or diffuse peritonitis is not uncommon. The question remains why and when acute appendicitis progresses to perforation. The aim of this study was to assess the impact of water permeability on the severity of appendicitis. We show that AQP1 expression and water permeability in appendicitis correlate with the stage of inflammation and systemic infection parameters, leading eventually to perforation of the appendix. AQP1 is also expressed within the ganglia of the enteric nervous system and ganglia count increases with inflammation. Severity of appendicitis can be correlated with water permeability measured by AQP1 protein expression and increase of ganglia count in a progressive manner. This introduces the question if regulation of water permeability can present novel curative or ameliorating therapeutic options.
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Affiliation(s)
- Nicola Pini
- a Department of Pediatric Surgery , University Childrens' Hospital of Basel (UKBB) , Basel , Switzerland
| | - Viktoria A Pfeifle
- a Department of Pediatric Surgery , University Childrens' Hospital of Basel (UKBB) , Basel , Switzerland
| | - Urs Kym
- a Department of Pediatric Surgery , University Childrens' Hospital of Basel (UKBB) , Basel , Switzerland
| | - Simone Keck
- a Department of Pediatric Surgery , University Childrens' Hospital of Basel (UKBB) , Basel , Switzerland
| | - Virginie Galati
- a Department of Pediatric Surgery , University Childrens' Hospital of Basel (UKBB) , Basel , Switzerland
| | - Stefan Holland-Cunz
- a Department of Pediatric Surgery , University Childrens' Hospital of Basel (UKBB) , Basel , Switzerland
| | - Stephanie J Gros
- a Department of Pediatric Surgery , University Childrens' Hospital of Basel (UKBB) , Basel , Switzerland
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Church JT, Klein EJ, Carr BD, Bruch SW. Early appendectomy reduces costs in children with perforated appendicitis. J Surg Res 2017; 220:119-124. [PMID: 29180172 DOI: 10.1016/j.jss.2017.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Perforated appendicitis can be managed with early appendectomy, or nonoperative management followed by interval appendectomy. We aimed to identify the strategy with the lowest health care utilization and cost. METHODS We retrospectively reviewed the medical records of all children ≤18 years old with perforated appendicitis admitted to a single institution between January 2009 and March 2016. After excluding immunosuppressed patients and transfers from outside hospitals, we grouped the remaining patients by early or interval appendectomy. Cost accounting data were obtained from our institutional database. The primary outcome was total hospital cost over 2 y from initial admission for appendicitis. Other outcomes analyzed included initial admission costs, number of admissions, emergency room and clinic visits, percutaneous procedures, cross-sectional and overall imaging studies, and length of stay. RESULTS A total of 203 children with perforated appendicitis were identified. After exclusion of immunosuppressed patients and outside hospital transfers, 94 patients were included in the study. Thirty-nine underwent early appendectomy and 55 initial nonoperative management; of these, 54 underwent elective interval appendectomy. Five of 55 patients (9%) failed initial nonoperative management and required earlier-than-planned appendectomy. Total cost over 2 y was significantly lower with early appendectomy than initial nonoperative management ($19,300 ± 14,300 versus $26,000 ± 17,500; P = 0.05). Early appendectomy resulted in fewer hospital admissions, clinic visits, invasive procedures, and imaging studies. CONCLUSIONS Early appendectomy results in lower hospital costs and less health care utilization compared with initial nonoperative management with elective interval appendectomy. A prospective study will shed more light on this question and can assess the role of nonoperative management without interval appendectomy in children with perforated appendicitis.
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Affiliation(s)
- Joseph T Church
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.
| | - Edwin J Klein
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin D Carr
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven W Bruch
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
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Sadraei-Moosavi SM, Nikhbakhsh N, Darzi AA. Postoperative antibiotic therapy after appendectomy in patients with non-perforated appendicitis. CASPIAN JOURNAL OF INTERNAL MEDICINE 2017; 8:104-107. [PMID: 28702149 PMCID: PMC5494044 DOI: 10.22088/cjim.8.2.104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Appendectomy intra-abdominal is the most frequently performed emergency surgery. This study was conducted to determine the role of postoperative antibiotics in reducing surgical site infections (SSIs) and abscess formation after open appendectomy. METHODS In the Department of Surgery, Shahid Beheshti Hospital, Babol, Iran, from October 2013 to October 2014 one hundred and fifty two patients, who underwent appendectomy for nonperforated appendicitis (NPA) and fulfilled the selection criteria, were randomized into two groups. Group A patients received a single dose of preoperative antibiotics (ceftriaxone and metronidazole) and group B patients received the same regimen, in addition, antibiotics were administered 24 hours postoperatively. Patients of both groups were followed-up for 30 days to assess the postoperative infectious complications. RESULTS Both groups comprised 76 patients, as well both groups were compared in baseline characteristics. Statistically, there was no significant difference in rates of SSIs between both groups. None of the patients developed intra-abdominal collection. CONCLUSION Single dose of preoperative antibiotics (ceftriaxone and metronidazole) was sufficient in reducing SSIs after appendectomy for NPA. Postoperative antibiotics did not add an appreciable clinical benefit in these patients.
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Affiliation(s)
| | - Novin Nikhbakhsh
- Cancer Research Center, Health Research Institue, Babol University of Medical Sciences, Babol, Iran.,Department of Surgery, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Ali-Asghar Darzi
- Cancer Research Center, Health Research Institue, Babol University of Medical Sciences, Babol, Iran.,Department of Surgery, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran
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45
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Park HC, Kim MJ, Lee BH. Effect of a Standardized Protocol of Antibiotic Therapy on Surgical Site Infection after Laparoscopic Surgery for Complicated Appendicitis. Surg Infect (Larchmt) 2017. [PMID: 28631985 DOI: 10.1089/sur.2017.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although it is accepted that complicated appendicitis requires antibiotic therapy to prevent post-operative surgical infections, consensus protocols on the duration and regimens of treatment are not well established. This study aimed to compare the outcome of post-operative infectious complications in patients receiving old non-standardized and new standard antibiotic protocols, involving either 5 or 10 days of treatment, respectively. METHODS We enrolled 1,343 patients who underwent laparoscopic surgery for complicated appendicitis between January 2009 and December 2014. At the beginning of the new protocol, the patients were divided into two groups; 10 days of various antibiotic regimens (between January 2009 and June 2012, called the non-standardized protocol; n = 730) and five days of cefuroxime and metronidazole regimen (between July 2012 and December 2014; standardized protocol; n = 613). We compared the clinical outcomes, including surgical site infection (SSI) (superficial and deep organ/space infections) in the two groups. RESULTS The standardized protocol group had a slightly shorter operative time (67 vs. 69 min), a shorter hospital stay (5 vs. 5.4 d), and lower medical cost (US$1,564 vs. US$1,654). Otherwise, there was no difference between the groups. No differences were found in the non-standardized and standard protocol groups with regard to the rate of superficial infection (10.3% vs. 12.7%; p = 0.488) or deep organ/space infection (2.3% vs. 2.1%; p = 0.797). CONCLUSIONS In patients undergoing laparoscopic surgery for complicated appendicitis, five days of cefuroxime and metronidazole did not lead to more SSIs, and it decreased the medical costs compared with non-standardized antibiotic regimens.
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Affiliation(s)
- Hyoung-Chul Park
- Department of Surgery, Hallym University College of Medicine , Anyang, Republic of Korea
| | - Min Jeong Kim
- Department of Surgery, Hallym University College of Medicine , Anyang, Republic of Korea
| | - Bong Hwa Lee
- Department of Surgery, Hallym University College of Medicine , Anyang, Republic of Korea
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46
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 306] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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Hurst AL, Olson D, Somme S, Child J, Pyle L, Ranade D, Stamatoiu A, Crombleholme T, Parker SK. Once-Daily Ceftriaxone Plus Metronidazole Versus Ertapenem and/or Cefoxitin for Pediatric Appendicitis. J Pediatric Infect Dis Soc 2017; 6:57-64. [PMID: 26703242 DOI: 10.1093/jpids/piv082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/15/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Appendicitis is a common surgical emergency in pediatric patients, and broad-spectrum antibiotic therapy is warranted in their care. A simplified once-daily regimen of ceftriaxone and metronidazole (CTX plus MTZ) is cost effective in perforated patients. The goal of this evaluation is to compare a historic regimen of cefoxitin (CFX) in nonperforated cases and ertapenem (ERT) in perforated and abscessed cases with CTX plus MTZ for all cases in terms of efficacy and cost. METHODS A retrospective review compared outcomes of nonperforated, perforated, and abscessed cases who received the historic regimen or CTX plus MTZ. Length of stay, time to afebrile, time to full feeds, postoperative abscess, and wound infection rates, inpatient readmissions, and antibiotic costs were evaluated. RESULTS There were a total of 841 cases reviewed (494 nonperforated, 247 perforated, and 100 abscessed). Overall, the CTX plus MTZ group had a shorter time to afebrile (P < .001). Treatment groups did not differ in length of stay. Postoperative abscess rates were similar between groups (4.1% vs 3.3%, not significant). Other postoperative complications were similar between groups. Total antibiotic cost savings were over $110 000 during the study period (from November 2010 to June 2013). CONCLUSIONS Both CFX and/or ERT and CTX plus MTZ result in low abscess and complication rates, suggesting both are effective strategies. Treatment with CTX plus MTZ results in a shorter time to afebrile, while also providing significant antibiotic cost savings. Ceftriaxone plus MTZ is a streamlined, cost-effective regimen in the treatment of nonperforated, perforated, and abscessed appendicitis.
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Affiliation(s)
| | - Daniel Olson
- Department of Pediatrics.,Division of Pediatric Infectious Diseases
| | - Stig Somme
- Department of Pediatrics.,Division of General, Thoracic, and Fetal Pediatric Surgery
| | | | | | - Daksha Ranade
- Division of Clinical Informatics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | | | - Timothy Crombleholme
- Department of Pediatrics.,Division of General, Thoracic, and Fetal Pediatric Surgery
| | - Sarah K Parker
- Department of Pediatrics.,Division of Pediatric Infectious Diseases.,Department of Infection Control
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Sherratt FC, Eaton S, Walker E, Beasant L, Blazeby JM, Young B, Crawley E, Wood WW, Hall NJ. Development of a core outcome set to determine the overall treatment success of acute uncomplicated appendicitis in children: a study protocol. BMJ Paediatr Open 2017; 1:e000151. [PMID: 29637158 PMCID: PMC5862231 DOI: 10.1136/bmjpo-2017-000151] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/20/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION In recent years, there has been growing interest in alternatives to appendicectomy. In particular, non-operative treatment of appendicitis, with antibiotics alone, has been proposed as a potential treatment. A small number of randomised controlled trials (RCTs) in adults and, more recently, children suggest that antibiotic treatment may be a valid alternative to appendicectomy. However, there is currently insufficient data to justify its widespread use. Prior to performing further efficacy studies of the treatment of appendicitis in children, it is imperative to identify the most relevant outcome measures for inclusion in the design of comparative studies. This is of particular importance when evaluating a novel treatment approach since the outcomes of importance may differ from those commonly reported with traditional therapies.A review of the relevant literature and electronic resources failed to identify a core outcome set (COS) for children with appendicitis. We aim to define a COS for the measurement of treatment interventions in children (<18 years) with acute appendicitis. METHODS AND ANALYSIS This project will entail: (1) a systematic review to identify previously reported acute uncomplicated appendicitis treatment outcomes; (2) assembly of stakeholder panels (paediatric and adult surgeons, patients and parents); (3) a three-stage Delphi process; and (4) a final consensus meeting to complete the COS. ETHICS AND REGISTRATION COS development is part of CONservative TReatment of Appendicitis in Children - a randomised controlled Trial (Feasibility) (CONTRACT) study, for which full ethical approval for CONTRACT has been granted. The COS development study is registered with the COMET Initiative in May 2017 (http://www.comet-initiative.org/studies/details/987).
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Affiliation(s)
- Frances C Sherratt
- Department of Psychological Sciences, Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Simon Eaton
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Erin Walker
- Great Ormond Street Hospital NHS Foundation Trust, London, London, UK
| | - Lucy Beasant
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Bridget Young
- Department of Psychological Sciences, Institute of Psychology, Health & Society, University of Liverpool, Liverpool, UK
| | - Esther Crawley
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Wendy W Wood
- Research Design Services South Central, University of Southampton, Southampton, UK
| | - Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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49
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Putnam LR, Ostovar-Kermani TG, Le Blanc A, Anderson KT, Holzmann-Pazgal G, Lally KP, Tsao K. Surgical site infection reporting: more than meets the agar. J Pediatr Surg 2017; 52:156-160. [PMID: 27863822 DOI: 10.1016/j.jpedsurg.2016.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 10/20/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Surgical site infection (SSI) rate in pediatric appendicitis is a commonly used hospital quality metric. We hypothesized that surveillance of organ-space SSI (OSI) using cultures alone would fail to capture many clinically-important events. METHODS A prospective, multidisciplinary surveillance program recorded 30-day SSI and hospital length of stay (LOS) for patients <18years undergoing appendectomy for perforated appendicitis from 2012 to 2015. Standardized treatment pathways were utilized, and OSI was identified by imaging and/or bacterial cultures. RESULTS Four hundred ten appendectomies for perforated appendicitis were performed, and a total of 84 OSIs (20.5%) were diagnosed with imaging. Positive cultures were obtained for 39 (46%) OSIs, whereas 45 (54%) had imaging only. Compared to the mean LOS for patients without OSI (5.2±2.9days), LOS for patients with OSI and positive cultures (13.7±5.4days) or with OSI without cultures (10.4±3.7days) was significantly longer (both p<0.001). The OSI rate identified by positive cultures alone was 9.5%, whereas the clinically-relevant OSI rate was 20.5%. CONCLUSIONS Using positive cultures alone to capture OSI would have identified less than half of clinically-important infections. Utilizing clinically-relevant SSI is an appropriate metric for comparing hospital quality but requires agreed upon standards for diagnosis and reporting. LEVEL OF EVIDENCE II. TYPE OF STUDY Diagnostic study.
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Affiliation(s)
- Luke R Putnam
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Tiffany G Ostovar-Kermani
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Andrea Le Blanc
- Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kathryn T Anderson
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Galit Holzmann-Pazgal
- Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kevin P Lally
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
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50
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Lee YR, McMahan D, McCall C, Perry GK. Complicated Intra-Abdominal Infections: The Old Antimicrobials and the New Players. Drugs 2016; 75:2097-117. [PMID: 26612473 DOI: 10.1007/s40265-015-0506-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Complicated intra-abdominal infections (cIAIs) are an important cause of morbidity and mortality worldwide. They are diagnosed when the initial abdominal organ infection has spread into the peritoneal space. Successful treatment relies on adequate source control and appropriate empiric antimicrobial therapy. Inappropriate antimicrobial therapy may result in poor patient outcomes and increases in healthcare costs. Current guidelines recommend several single and combination antimicrobial regimens; however, empiric antimicrobial treatment has been complicated by the increasing rates of resistant organisms, especially the extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. Additionally, the overuse of carbapenems to combat these resistant pathogens has contributed to the rise of carbapenemase-producing microorganisms, especially Klebsiella pneumoniae. This increasing resistance has prompted the development of novel antimicrobials like ceftazidime-avibactam and ceftolozane-tazobactam, whose activity extends to ESBL-producing microorganisms. Furthermore, the optimal duration of antimicrobial therapy is still unknown, and further research is necessary to find a definitive answer. This review will focus on antimicrobial therapies recommended by the current guidelines, the individual properties of these agents, appropriate duration of therapy, recent clinical trials, and place in therapy of the antimicrobial agents recently approved for the treatment of cIAIs.
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Affiliation(s)
- Young R Lee
- Texas Tech University Health Sciences Center School of Pharmacy, 1718 Pine Street, Abilene, TX, 79601, USA.
| | - Danni McMahan
- Texas Tech University Health Sciences Center School of Pharmacy, 1718 Pine Street, Abilene, TX, 79601, USA.
| | - Catherine McCall
- Texas Tech University Health Sciences Center School of Pharmacy, 1718 Pine Street, Abilene, TX, 79601, USA.
| | - Gregory K Perry
- Hendrick Medical Center, 1900 Pine Street, Abilene, TX, 79601, USA.
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