Rational use of antibiotics for perforated appendicitis in childhood

The avoidable excesses in the management of perforated appendicitis in children

During a five-year period from 1979 to 1985, 100 consecutive children with perforated appendicitis were managed at our institution. These patients were divided into two groups, which were determined by length of illness and physical findings. Group A consisted of 88 children with signs and symptoms of peritonitis from appendiceal perforation. They were treated with fluid resuscitation, antipyretics, and triple antibiotics (ampicillin, gentamicin, clindamycin), and appendectomy within a few hours of hospitalization. Saline lavage was used. Group B was composed of 12 patients with a periappendiceal mass without generalized peritonitis who had symptoms of 6 to 12 days duration. They were treated nonoperatively with triple antibiotics and underwent interval appendectomy 4 to 6 weeks later. The complication rate for Group A was 6.8%. This included three wound infections (3.4%), one intra-abdominal abscess (1.1%), one patient with pneumonia and ileus (1.1%), and a small bowel obstruction (1.1%). These results are equivalent to the lowest complication rate reported in the literature, in which the treatment included transperitoneal drainage, antibiotic lavage, and parenteral antibiotics. Group B patients had a 16.7% complication rate, which included one small bowel obstruction and one recurrent intra-abdominal abscess. Our method of management resulted in the lowest complication rate reported to date in children with perforated appendicitis. Transperitoneal drainage, delayed wound closure, and antibiotic lavage were not used. Subcuticular incisional closure resulted in minimal wound care and excellent cosmetic results. The experience demonstrates that with proper timing of surgery and appropriate use of contemporary antibiotics, the morbidity of perforated appendicitis can be limited and excesses of treatment can be avoided.

Wound and intraperitoneal infection following appendicectomy for perforated or gangrenous appendicitis

A series of 158 children, who were operated on for perforated or gangrenous appendicitis between 1980 and 1984 inclusive, are reviewed. A protocol of management, based on the results of bacteriology of the perforated appendix was introduced and the guidelines followed in all but four instances. Eight patients (5.0%) developed postoperative infections, either in the wound or intraperitoneally. The frequency of infection was affected by the adherence to protocol, as 50% of the infections occurred in patients who did not receive preoperative antibiotic prophylaxis. The use of drainage also contributed to the frequency of wound infection. Thorough peritoneal lavage and meticulous surgical technique should reduce the need for drainage.

Abdominal pain unrelated to trauma

This article reviews the more common causes of abdominal pain in children. It is divided into three sections to emphasize differential diagnosis. For some problems responsible for abdominal pain surgery is essential, for some surgery may not be initially required but may be unavoidable, and for others the condition is purely medical and surgery should be avoided. Armed with a complete differential diagnosis, the general surgical resident may avoid many pitfalls.

Role of amikacin in the management of intra-abdominal sepsis

Controversy has developed regarding the antibiotic management of intra-abdominal sepsis because of the recent availability of the third-generation cephalosporins and ureidopenicillins as alternatives to traditional combination therapy (aminoglycosides plus clindamycin). Most observers now acknowledge the need to provide anti-anaerobic as well as anti-aerobic gram-negative drug coverage. Although most of the newer agents do provide such broad-spectrum coverage, doubt remains regarding their efficacy because of flaws in comparative study design and the observation that resistance to the newer agents, which may even extend to the aminoglycosides, can emerge in individual patients during single courses of antibiotic therapy. Indeed, such resistance is most likely to occur during the treatment of seriously ill, immunodepressed patients who have undergone multiple reoperation for persistent or recurrent intra-abdominal sepsis--the precise group for which the new drugs were most desired as less toxic alternatives to the aminoglycosides. On the basis of such observations, combination therapy with the aminoglycosides, appears to remain the most logical choice. In the setting of nosocomial sepsis and pathogen resistance to other aminoglycosides, amikacin may be especially effective. Recent surveillance data indicate that the use of amikacin under such circumstances not only may provide effective antibiotic therapy, but also may actually reduce the level of microbial resistance to the other aminoglycosides. Past concern regarding the development of resistance to amikacin has probably been excessive and should not deter the use of this agent under appropriate clinical circumstances.

Streptococcus milleri in appendicitis in children

A retrospective survey of 253 appendectomies performed on children over a period of one year was carried out. Streptococcus milleri was isolated from pus in 11 (29%) of the 38 children who developed postoperative infections; it was the most commonly identified pathogen in these children. It is concluded that S milleri is a significant pathogen in childhood appendicitis, and that this fact should be taken into account when antibiotic therapy is being planned.