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Russell KW, Skarda DE, Jones TW, Barnhart DC, Short SS. Cessation of Antibiotics for Complicated Appendicitis at Discharge Does Not Increase Risk of Post-operative Infection. J Pediatr Surg 2024; 59:91-95. [PMID: 37858398 DOI: 10.1016/j.jpedsurg.2023.09.023] [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: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE The utilization of home antibiotic therapy following surgery for complicated pediatric appendicitis is highly variable. In 2019, we stopped home antibiotic therapy in this cohort at our institution. We sought to evaluate our outcomes following this protocol change. METHODS We queried our institutional NSQIP Pediatrics data for all children undergoing appendectomy for complicated appendicitis between January 2015 and May 2022. We identified two cohorts: those discharged with home antibiotics (1/1/15-4/30/19) and those discharged with no home antibiotics (5/1/19-4/30/22). Both groups were treated with response based parenteral antibiotics while hospitalized and discharged when clinically well. Our primary outcome was postoperative deep organ space infection requiring intervention (drainage, aspiration, reoperation, or antibiotics). Secondary outcomes included length of stay, superficial site infection, Clostridium difficile colitis, ER visits, post-operative CT imaging, and readmission. RESULTS There were 185 patients in the home antibiotic group (83% discharged with antibiotics) and 121 patients in the no home antibiotic group (8.3% discharged with antibiotics). There were no significant differences in deep organ space infection requiring intervention (7% vs. 7.4%, p = 1.0). Our length of stay was not different (4.5 days vs. 3.95 days, p = 0.32), nor were other secondary outcomes or patient characteristics. All patients had documented follow-up. CONCLUSIONS We did not identify differences in deep organ space infections, length of stay or other events after eliminating home antibiotic therapy in our complicated appendicitis cohort. The use of home antibiotics following surgery for complicated appendicitis should be reconsidered. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Katie W Russell
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - David E Skarda
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Trahern W Jones
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Douglas C Barnhart
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Scott S Short
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA.
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2
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Won M, Ahn C. Epidemiology and Outcome of Acute Appendicitis during and before the COVID-19 Pandemic: A Retrospective Single-Center Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050902. [PMID: 37241134 DOI: 10.3390/medicina59050902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: We investigated epidemiological factors and outcomes, including the development of complications, for patients with appendicitis according to three sequential coronavirus disease 2019 (COVID-19) pandemic periods, divided by specific time points. Materials and Methods: This observational study included patients with acute appendicitis who arrived at a single-center between March 2019 and April 2022. The study divided the pandemic into three periods: period A as the first phase of the pandemic (from 1 March 2020 to 22 August 2021), period B as the time period the medical system stabilized (from 23 August 2021 to 31 December 2021), and period C as the time period of the exploration of patients with COVID-19 in South Korea (from 1 January 2022 to 30 April 2022). Data collection was based on medical records. The primary outcome was presence or absence of complications and the secondary outcomes were the time taken from ED visit to surgical intervention, the presence and time of the first administration of antibiotics, and the hospital stay time. Results: Of 1,101 patients, 1,039 were included, with 326 and 711 patients before and during the pandemic, respectively. Incidence of complications was not affected during the pandemic (before the pandemic 58.0%; period A 62.7%; period B,55.4%; and period C 58.1%; p = 0.358). Time from symptom onset to emergency department (ED) arrival significantly decreased during the pandemic (before the pandemic 47.8 ± 84.3 h; pandemic 35.0 ± 54 h; p = 0.003). Time from ED visit to the operating room was statistically significantly increased during the pandemic (before the pandemic 14.3 ± 21.67 h; period A 18.8 ± 14.02 h; period B 18.8 ± 8.57 h; period C 18.3 ± 12.95 h; p = 0.001). Age and time from symptom onset to ED arrival were variables affecting the incidence of complications; however, they were not affected during the pandemic (age, OR 2.382; 95% CI 1.545-3.670; time from symptom onset to ED arrival, OR 1.010, 95% CI 1.006-1.010; p < 0.001). Conclusions: This study found no differences in postoperative complications or treatment durations between pandemic periods. The incidence of appendicitis complications was significantly influenced by age and the duration between the onset of symptoms and arrival at the emergency department, but not by the pandemic period itself.
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Affiliation(s)
- Moonho Won
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea
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3
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de Wijkerslooth EML, Boerma EJG, van Rossem CC, van Rosmalen J, Baeten CIM, Beverdam FH, Bosmans JWAM, Consten ECJ, Dekker JWT, Emous M, van Geloven AAW, Gijsen AF, Heijnen LA, Jairam AP, Melles DC, van der Ploeg APT, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BPL, van den Boom AL. 2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial. Lancet 2023; 401:366-376. [PMID: 36669519 DOI: 10.1016/s0140-6736(22)02588-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/20/2022] [Accepted: 11/18/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND The appropriate duration of postoperative antibiotics for complex appendicitis is unclear. The increasing global threat of antimicrobial resistance warrants restrictive antibiotic use, which could also reduce side-effects, length of hospital stay, and costs. METHODS In this pragmatic, open-label, non-inferiority trial in 15 hospitals in the Netherlands, patients with complex appendicitis (aged ≥8 years) were randomly assigned (1:1) to receive 2 days or 5 days of intravenous antibiotics after appendicectomy. Randomisation was stratified by centre, and treating physicians and patients were not masked to treatment allocation. The primary endpoint was a composite endpoint of infectious complications and mortality within 90 days. The main outcome was the absolute risk difference (95% CI) in the primary endpoint, adjusted for age and severity of appendicitis, with a non-inferiority margin of 7·5%. Outcome assessment was based on electronic patient records and a telephone consultation 90 days after appendicectomy. Efficacy was analysed in the intention-to-treat and per-protocol populations. Safety outcomes were analysed in the intention-to-treat population. This trial was registered with the Netherlands Trial Register, NL5946. FINDINGS Between April 12, 2017, and June 3, 2021, 13 267 patients were screened and 1066 were randomly assigned, 533 to each group. 31 were excluded from intention-to-treat analysis of the 2-day group and 30 from the 5-day group owing to errors in recruitment or consent. Appendicectomy was done laparoscopically in 955 (95%) of 1005 patients. The telephone follow-up was completed in 664 (66%) of 1005 patients. The primary endpoint occurred in 51 (10%) of 502 patients analysed in the 2-day group and 41 (8%) of 503 patients analysed in the 5-day group (adjusted absolute risk difference 2·0%, 95% CI -1·6 to 5·6). Rates of complications and re-interventions were similar between trial groups. Fewer patients had adverse effects of antibiotics in the 2-day group (45 [9%] of 502 patients) than in the 5-day group (112 [22%] of 503 patients; odds ratio [OR] 0·344, 95% CI 0·237 to 0·498). Re-admission to hospital was more frequent in the 2-day group (58 [12%] of 502 patients) than in the 5-day group (29 [6%] of 503 patients; OR 2·135, 1·342 to 3·396). There were no treatment-related deaths. INTERPRETATION 2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days in terms of infectious complications and mortality within 90 days, based on a non-inferiority margin of 7·5%. These findings apply to laparoscopic appendicectomy conducted in a well resourced health-care setting. Adopting this strategy will reduce adverse effects of antibiotics and length of hospital stay. FUNDING The Netherlands Organization for Health Research and Development.
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Affiliation(s)
| | | | | | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC - University Medical Centre, Rotterdam, Netherlands; Department of Epidemiology, Erasmus MC - University Medical Centre, Rotterdam, Netherlands
| | - Coen I M Baeten
- Department of Surgery, Groene Hart Hospital, Gouda, Netherlands
| | | | | | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands; Department of Surgery, University Medical Centre Groningen, Netherlands
| | | | - Marloes Emous
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | | | - Anton F Gijsen
- Department of Surgery, Medical Spectrum Twente, Enschede, Netherlands
| | - Luc A Heijnen
- Department of Surgery, Northwest Clinics, Alkmaar, Netherlands
| | - An P Jairam
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands
| | - Damian C Melles
- Department of Medical Microbiology and Medical Immunology, Meander Medical Centre, Amersfoort, Netherlands
| | | | | | | | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle aan den Ijssel, Netherlands
| | - Bas Wiering
- Department of Surgery, Slingeland Hospital, Doetinchem, Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Centre, Rotterdam, Netherlands.
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4
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Kroon HM, Kenyon-Smith T, Nair G, Virgin J, Thomas B, Juszczyk K, Hollington P. Safety and efficacy of short-course intravenous antibiotics after complicated appendicitis in selected patients. Acta Chir Belg 2023; 123:49-53. [PMID: 34120572 DOI: 10.1080/00015458.2021.1940726] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND After surgery for complicated appendicitis (CA), common practice is to treat all patients with a standardised long-course of intravenous antibiotics (IVAB) to reduce the risk of postoperative surgical infections (PSI). The aim of the current study was to evaluate the safety and efficacy of a short-course IVAB after CA in selected patients. METHODS The Department's prospectively collected database identified CA patients treated between2015 and 2019. Baseline and treatment characteristics and postoperative outcomes were analysed. The cut-off between short- and long-course IVAB was 2 days. Outcomes of interest were PSI and 30-day unplanned readmission. RESULTS In total, 226 patients had CA: Ninety-nine CA (43.8%) received short-course IVAB and 127 (56.2%) received long-course. PSI occurred in 6% and 10% of the short-course and long-course patients, respectively (p = 0.34). Length of IVAB after a PSI was comparable to that of patients without PSI (median 3 and 2 days of IVAB respectively; p = 0.28). 30-day unplanned readmission rates were 7% and 6%, respectively (p = 0.99). Length of IVAB for readmitted patients was similar to those who were not readmitted (median 3 days of IVAB in both; p = 0.91). Multivariable analysis showed that the intraoperative findings of the appendix (p = 0.04) was a prognostic predictor for PSI. ASA score (p = 0.02) and surgical approach (p = 0.05) were prognostic predictors for 30-day unplanned readmission. CONCLUSIONS This study shows that when patients respond well, a short-course IVAB can safely be applied after CA without increasing risk of PSI or 30-day unplanned readmission.
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Affiliation(s)
- Hidde M Kroon
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Tim Kenyon-Smith
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Gavin Nair
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - James Virgin
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Bev Thomas
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Karolina Juszczyk
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Paul Hollington
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
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5
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Membrilla-Fernández E, Gómez-Zorrilla S, González-Castillo AM, Pelegrina-Manzano A, Guzmán-Ahumada J, Prim N, Echeverria-Esnal D, Grau-Cerrato S, Horcajada-Gallego JP, Badía JM, Sancho-Insenser JJ. Scientific evidence of the duration of antibiotic treatment in intra-abdominal infections with surgical focus control. Cir Esp 2022; 100:608-613. [PMID: 35760316 DOI: 10.1016/j.cireng.2022.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/22/2022] [Indexed: 06/15/2023]
Abstract
A non-systematic review of the published scientific evidence has been carried out on the duration of empirical antibiotic treatment in surgical intra-abdominal infections (IIA) with effective focus control. Given the progressive increase in antibiotic resistance, it is urgent to have strategies to reduce the pressure on the microbiota. The American guidelines made by Mazuski et al. of 20171, as the central axis in the recommendations of the duration of empirical antibiotic treatment in intra-abdominal infections with control of the focus and a bibliographic search of all the articles that contained the keywords in Pubmed and Google Scholar is added. 21 articles referring to the duration of empirical antibiotic treatment in intra-abdominal infection with control of the focus are collected. With the American guidelines and these articles, a proposal is prepared for the duration of empirical antibiotic treatment in patients without risk factors between 24 and 72 h. And in those who present risk factors, it should be individualized with active monitoring every 24 h of fever, paralytic ileus and leukocytosis (FIL), before an early detection of complications or the need for changes in antibiotic treatment. Short treatments are just as effective as those of longer durations and are associated with fewer adverse effects, therefore, daily adjusting and reassessing the duration of empirical antibiotic treatment is essential for better practice.
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Affiliation(s)
| | | | | | | | - Juan Guzmán-Ahumada
- Servicio de Cirugía General y Aparato Digestivo, Hospital del Mar de Barcelona, Spain
| | - Nuria Prim
- Servicio de Microbiología, Laboratorio de Referencia de Cataluña, Spain
| | | | | | | | - Josep María Badía
- Servicio de Cirugía General y Aparato Digestivo, Hospital de Granollers, Universitat Internacional de Catalunya, Spain
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6
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Characteristics of appendicitis after immune checkpoint inhibitor therapy among cancer patients. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04367-6. [PMID: 36163559 DOI: 10.1007/s00432-022-04367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/16/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Immune checkpoint inhibitor (ICI) therapy has revolutionized cancer care but is associated with immune-related adverse events (irAEs). Recent case reports raised the concern that acute appendicitis may be an irAE. In this study, we sought to describe the disease course of post-ICI therapy appendicitis and its associated complications. METHODS Adult patients who had an International Classification of Diseases code for appendicitis within the first 2 years after initiating ICI therapy from January 2010 to April 2021 and who had imaging evidence of appendicitis were studied retrospectively. RESULTS 13,991 patients were identified who had ICI exposure during the study period, 44 had codes for appendicitis, 10 of whom met the inclusion criteria. Their median age at the time of diagnosis was 59 years. The median time from ICI therapy initiation to appendicitis onset was 188 days. The most common presenting symptoms were abdominal pain (70%) and fever (40%). Abscesses were present in two patients, and a perforation was present in one. All 10 patients received broad-spectrum antibiotics. Five patients needed surgery or interventional radiology drainage. Nine patients had resolution of appendicitis symptoms after treatment. CONCLUSION Post-ICI therapy appendicitis is rare but presents similarly to and has similar complications rates as conventional appendicitis. Appendectomy remains the mainstay of treatment, but its use can be limited in cancer patients. The decision to continue ICI therapy remains at the discretion of the clinician. Further studies are needed to bring awareness to and advance the understanding of this clinical entity.
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7
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Chammas M, Pust GD, Hatton G, Pedroza C, Kao L, Rattan R, Namias N, Yeh DD. Outcomes of Restricted versus Liberal Post-Operative Antibiotic Use in Patients Undergoing Appendectomy: A DOOR/RADAR Post Hoc Analysis of the EAST Appendicitis MUSTANG Study. Surg Infect (Larchmt) 2022; 23:489-494. [PMID: 35647893 DOI: 10.1089/sur.2021.287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: There is no consensus on the duration of antibiotic use after appendectomy. We hypothesized that restricted antibiotic use is associated with better clinical outcomes. Patients and Methods: We performed a post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America-Acute, Perforated, and Gangrenous (MUSTANG) study using the desirability of outcome ranking/response adjusted for duration of antibiotic risk (DOOR/RADAR) framework. Three separate datasets were analyzed based on restricted versus liberal post-operative antibiotic groups: simple appendicitis (no vs. yes); complicated appendicitis, only four days (≤24 hours vs. 4 days); and complicated appendicitis, four or more days (≤24 hours vs. ≥4 days). Patients were assigned to one of seven mutually exclusive DOOR categories RADAR ranked within each category. DOOR/RADAR score pairwise comparisons were performed between all patients. Each patient was assigned either 1, 0, or -1 if they had better, same, or worse outcomes than the other patient in the pair, respectively. The sum of these numbers (cumulative comparison score) was calculated for each patient and the group medians of individual sums were compared by Wilcoxon rank sum. Results: For simple appendicitis, the restricted group had higher median sums than the liberal group (552 [552,552] vs. -1,353 [-1,353, -1,353], p < 0.001). For both complicated appendicitis analyses, the restricted group had higher median sums than the liberal: only 4 (196 [23,196] vs. -121 [-121, -121], p < 0.02) and 4 or more (660 [484,660] vs -169 [-444,181], p < 0.001). Conclusions: Restricted post-operative antibiotic use in patients after appendectomy is a dominant strategy when considering treatment effectiveness and antibiotic exposure.
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Affiliation(s)
- Majid Chammas
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gerd Daniel Pust
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Gabrielle Hatton
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Claudia Pedroza
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Lillian Kao
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA.,McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
| | - D Dante Yeh
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami, Jackson Memorial Hospital Ryder Trauma Center, Miami, Florida, USA
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Elrod J, Yarmal F, Mohr C, Dennebaum M, Boettcher M, Vincent D, Reinshagen K, Koenigs I. Are We Hitting the Target?: The Effectiveness of Distinct Antibiotic Regimens in Pediatric Appendectomies. Pediatr Infect Dis J 2022; 41:460-465. [PMID: 35333833 DOI: 10.1097/inf.0000000000003508] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Currently, a range of different antibiotics are administered perioperatively during appendectomy surgery in the pediatric population. One reason for the lack of a uniform treatment regimen is the paucity of large studies on microbiologic data and susceptibility patterns. METHODS A retrospective, monocentric study on antibiotic susceptibility, including 1258 pediatric patients undergoing appendectomy from 2012 to 2020 was performed. Predictors for prolonged length of stay (LOS) and complications were determined using regression analysis, and objective criteria for broad-spectrum antibiotic regimens were identified. Simulations of the effectiveness of different antibiotic regimens against identified bacterial susceptibility results were conducted. RESULTS The most important predictors for prolonged LOS and an increased incidence of infectious complications are elevated preoperative C-reactive protein levels, high intraoperative severity gradings and insufficient primary antibiotic treatment. Based on our results, a simple antibiotic treatment, consisting of cefuroxime-metronidazole (C-M) or ampicillin-sulbactam (AS), is sufficient in around 85% of all patients; both options being equally efficient. In severe appendicitis, the likelihood of resistance is 31% and 32% for C-M and AS, respectively. For piperacillin-tazobactam and C-M-tobramycin, the incidence of bacterial resistance decreases to 12%. Resistance is reduced to 8% for AS-tobramycin treatment. The patient populations benefiting most from an extended antibiotic regimen are those with a high intraoperative severity grading. CONCLUSIONS Evidence suggests that an insufficient antibiotic regimen is associated with a prolonged LOS and a higher rate of infectious complications, justifying the expansion of a simple antibiotic regimen in cases of severe intraabdominal findings. In all other cases, a simple antibiotic treatment with AS is recommended.
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Affiliation(s)
- Julia Elrod
- From the Department of Pediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Fatima Yarmal
- From the Department of Pediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
| | - Christoph Mohr
- From the Department of Pediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
| | - Martin Dennebaum
- Institute of Clinical Microbiology and Hygiene, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Michael Boettcher
- From the Department of Pediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
- Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Deirdre Vincent
- From the Department of Pediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- From the Department of Pediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
- Department of Pediatric Surgery, Altona Children's Hospital, Hamburg, Germany
| | - Ingo Koenigs
- From the Department of Pediatric Surgery, University Medical Centre Eppendorf, Hamburg, Germany
- Department of Pediatric Surgery, Altona Children's Hospital, Hamburg, Germany
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9
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Membrilla-Fernández E, Gómez-Zorrilla S, González-Castillo AM, Pelegrina-Manzano A, Guzmán-Ahumada J, Prim N, Echeverria-Esnal D, Grau-Cerrato S, Horcajada-Gallego JP, Badía Pérez JM, Sancho-Insenser JJ. Evidencia científica de la duración del tratamiento antibiótico en las infecciones intraabdominales con control de foco quirúrgico. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Yan C, Cao J, Chen B, Guo C. Postoperative organ space infection (OSI) following appendectomy: early term evaluation for pediatric population. Updates Surg 2022; 74:1027-1033. [PMID: 34997547 DOI: 10.1007/s13304-021-01207-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
No consensus has been reached on the duration of antibiotic prophylaxis for postoperative organ space infection (OSI) following appendectomy. This study investigated the influence of antibiotic administration on postoperative OSIs in children with complex appendicitis. A multicenter, retrospective study was conducted in patients with OSI following complicated appendicitis between 2017 and 2019 at 3 hospitals in China. The qualified patients were dichotomized into a long-duration antibiotic group (> 5.5 days) and a short-duration antibiotic group (< 5.5 days) based on the median duration (5.5 days) of antibiotic administration. Potential biases in baseline characteristics were managed using propensity score matching for the two groups. Primary and secondary outcomes were compared between the two groups. Propensity-matched analysis of the entire cohort revealed no significant effects in terms of the time to OSI resolution (p = 0.16) or recurrence (p = 0.22) for the short-duration and long-duration antibiotic groups. A slightly lower complication rate, including the incidence of abdominal distention (p = 0.093) and antibiotic-associated diarrhea (p = 0.024), was noted in patients with short-duration antibiotic administration. Furthermore, no significant difference in readmission requirements (p = 0.14) or hospitalization duration (p = 0.102) was found between the two groups. For OSI following complicated appendicitis, long-term antibiotic administration did not provide a significant benefit.
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Affiliation(s)
- Chengwei Yan
- Department of Pediatric General Surgery, Chongqing University Three Gorges Hospital, Chongqing, People's Republic of China
| | - Jian Cao
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Bailin Chen
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China. .,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Chongqing, People's Republic of China. .,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
| | - Chunbao Guo
- Department of Pediatric General Surgery, Chongqing University Three Gorges Hospital, Chongqing, People's Republic of China. .,Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd., Chongqing, 400014, People's Republic of China. .,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, Chongqing, People's Republic of China. .,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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11
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Alam A, Rehman AU, Waheed D, Khan MH, Ahmad W, Bashir I. POST-OPERATIVE ORAL ANTIBIOTICS IN REDUCING FREQUENCY OF SURGICAL SITE INFECTION FOLLOWING NON-PERFORATED APPENDECTOMY IN POPULATION OF SOUTH WAZIRISTAN AGENCY, PAKISTAN. GOMAL JOURNAL OF MEDICAL SCIENCES 2021. [DOI: 10.46903/gjms/19.02.936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Background: Acute appendicitis is most frequent cause of acute abdomen in younger population, and surgical site infection (SSI) is commonest complication of appendectomy. The objective of this trial was to compare the efficacy of post-operative oral antibiotics versus placebo in reducing the frequency of surgical site infection (SSI) following appendectomy for non-perforated appendicitis in population of South Waziristan Agency, Pakistan.Materials Methods: The randomized placebo trial was conducted at Agency Headquarter Hospital, Wana, South Waziristan, Pakistan from October 1, 2016 to November 18, 2018. One hundred fifty (150) patients were randomly allocated into two groups, 75 in experimental group, to whom antibiotics were given and 75 in placebo group, to whom antibiotics were not given. Age groups and presence of SSI were two variables, being on nominal scale, were described by count and percentage with CI at 80%CL. McNemar chi-square test was applied to test the hypothesis to see the significance of difference between the experimental and placebo groups in terms of frequency of SSI at alpha .05.Results: SSI was present in nine (12%, 80%CI 7.19-16.80%) out of 75 cases in experimental group and in 12 (16%, 80%CI 10.57-21.42%) out of 75 cases in placebo group. McNemar chi-square test showed no significant difference between the experimental and placebo groups in terms of frequency of SSI (p=.2482).Conclusion: The results are comparable for post-operative oral antibiotics versus placebo in reducing the frequency of surgical site infection (SSI) following appendectomy for non-perforated appendicitis in population of South Waziristan Agency, Pakistan.
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Oba T, Yamada T, Matsuda A, Otani M, Matsuda S, Ohta R, Yoshida H, Sato N, Hirata K. Patient backgrounds and short‐term outcomes of complicated appendicitis differ from those of uncomplicated appendicitis. Ann Gastroenterol Surg 2021; 6:273-281. [PMID: 35261953 PMCID: PMC8889856 DOI: 10.1002/ags3.12523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 10/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background Appendicitis is classified as either complicated (CA) or uncomplicated (UA). Some authors have shown that the epidemiologic trends of CA and UA may differ. The aim of this study was to clarify differences in backgrounds and surgical outcomes between CA and UA patients. Methods This study was a cohort study. We extracted case data from the Japanese Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. Patients were classified into three groups, depending on whether they underwent emergency appendectomy for CA (CA group), emergency appendectomy for UA (UA group), or elective appendectomy (EA group). We evaluated patient characteristics and surgical outcomes for each group. Results We included 89,355 adult patients in the study, comprising 29,331 CA, 48,691 UA, and 11,333 EA patients. Old age, larger body mass index, smoking, and medication with antidiabetic drugs, oral corticosteroids, oral antiplatelet drugs, and oral anticoagulant drugs were independent risk factors for CA. The percentage of CA increased with age. In‐hospital mortality (0.15%, 0.02%, and 0.00%) and 30‐d mortality (0.09%, 0.01%, and 0.00%), respectively, of CA patients were significantly higher than those of the UA and EA groups. The duration of postoperative antibiotic administration, duration of fasting, and time before removal of a prophylactic drain were significantly longer in the CA group than in the UA and EA groups. Conclusion Backgrounds and treatment outcomes of CA and UA patients after emergency surgery are entirely different. Thus, the treatment strategy of CA and UA patients should differ accordingly.
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Affiliation(s)
- Takuya Oba
- Department of Surgery 1 School of Medicine University of Occupational and Environmental Health Fukuoka Japan
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Akihisa Matsuda
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Makoto Otani
- Occupational Health Data Science Centre University of Occupational and Environmental Health Fukuoka Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health School of Medicine University of Occupational and Environmental Health Fukuoka Japan
| | - Ryo Ohta
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Norihiro Sato
- Department of Surgery 1 School of Medicine University of Occupational and Environmental Health Fukuoka Japan
| | - Keiji Hirata
- Department of Surgery 1 School of Medicine University of Occupational and Environmental Health Fukuoka Japan
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13
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Laxague F, Angeramo CA, Schlottmann F. Development and Validation of a Novel Nomogram to Predict the Risk of Postoperative Intraabdominal Abscess after Laparoscopic Appendectomy. J Gastrointest Surg 2021; 25:2101-2103. [PMID: 33492578 DOI: 10.1007/s11605-020-04872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Francisco Laxague
- Department of Surgery, Hospital Aleman of Buenos Aires, Buenos Aires, Argentina
| | - Cristian A Angeramo
- Department of Surgery, Hospital Aleman of Buenos Aires, Buenos Aires, Argentina
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Ramson DM, Gao H, Penny-Dimri JC, Liu Z, Khong JN, Caruana CB, Campbell R, Jackson S, Perry LA. Duration of post-operative antibiotic treatment in acute complicated appendicitis: systematic review and meta-analysis. ANZ J Surg 2021; 91:1397-1404. [PMID: 33576567 DOI: 10.1111/ans.16615] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 12/17/2020] [Accepted: 01/06/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Appendicitis is the most frequent aetiology of acute abdominal pain requiring surgical treatment, with an estimated lifetime risk between 7% and 8%. Antibiotics play a substantial role in treatment, and there is considerable debate regarding the duration of antibiotics in treating appendicitis. METHODS We searched multiple databases from inception until June 2019 for peer-reviewed studies that compared different durations of antibiotic treatment after appendicectomy for acute complicated appendicitis in adults. We dichotomized reported data into short- and extended-term antibiotic use and controlled for different definitional thresholds in the meta-analysis. We generated risk ratios using restricted maximum likelihood methods and mixed effects modelling for each outcome of interest. RESULTS Four observational studies involving 847 participants were included in the meta-analysis. For the primary outcomes of intra-abdominal infection, we did not find a statistically significant difference between extended- and short-term antibiotic strategies for intra-abdominal infection (Risk ratio 0.92, 95% confidence interval (CI) 0.49-1.74). Three randomized controlled trials involving 291 participants were included in a separate meta-analysis. We found that extended antibiotic usage was not associated with a statistically significant reduced risk for intra-abdominal infection (RR 0.52, 95% CI 0.21-1.29) or surgical site skin infection (RR 1.44, 95% CI 0.43-4.81). CONCLUSION This systematic review and meta-analysis found that extended post-operative antibiotic treatment may not be associated with a reduced risk of intra-abdominal infection; however, meta-analysis was significantly limited by heterogeneity between studies and underpowered trials. Further large randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Dhruvesh M Ramson
- Department of Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Hugh Gao
- Department of Surgery, Monash Health, Melbourne, Victoria, Australia
| | | | - Zhengyang Liu
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Carla B Caruana
- Department of Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Ryan Campbell
- Department of Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Sarah Jackson
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Luke A Perry
- Department of Surgery, Monash Health, Melbourne, Victoria, Australia
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15
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Beyer-Berjot L, Patel V, Sirimanna P, Hashimoto DA, Berdah S, Darzi A, Aggarwal R. Implementation of a Surgical Simulation Care Pathway Approach to Training in Emergency Abdominal Surgery. World J Surg 2020; 44:696-703. [PMID: 31659411 DOI: 10.1007/s00268-019-05242-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Simulation-based care pathway approach (CPA) training is a novel approach in surgical education. The objective of the present study was to determine whether CPA was feasible for training surgical residents and could improve efficiency in patients' management. A common disease was chosen: acute appendicitis. METHODS All five junior residents of our department were trained in CPA: preoperative CPA consisted in virtual patients (VPs) presenting with acute right iliac fossa pain; intraoperative CPA involved a virtual competency-based curriculum for laparoscopic appendectomy (LAPP); finally, post-operative VP were reviewed after LAPP. Thirty-eight patients undergoing appendectomy were prospectively included before (n = 21) and after (n = 17) the training. All demographic and perioperative data were prospectively collected from their medical records, and time taken from admission to management was measured. RESULTS All residents had performed less than 10 LAPP as primary operator. Pre- and intraoperative data were comparable between pretraining and post-training patients. Times to liquid and solid diet were significantly reduced after training [7 h (2-20) vs. 4 (4-6); P = 0.004, and 17 h (4-48) vs. 6 (4-24); P = 0.005] without changing post-operative morbidity [4 (19%) vs. 0 (0); P = 0.11] and length of stay [48 h (30-264) vs. 44 (21-145); P = 0.22]. CONCLUSIONS CPA training is feasible in abdominal surgery. In the current study, it improved patients' management in terms of earlier oral intake.
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Affiliation(s)
- Laura Beyer-Berjot
- Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK. .,Centre for Surgical Teaching and Research (CERC), Faculté de Médecine Secteur Nord, Aix-Marseille University, 51 Boulevard Pierre Dramard, 13015, Marseille, France.
| | - Vishal Patel
- Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK
| | - Pramudith Sirimanna
- Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK
| | | | - Stéphane Berdah
- Centre for Surgical Teaching and Research (CERC), Faculté de Médecine Secteur Nord, Aix-Marseille University, 51 Boulevard Pierre Dramard, 13015, Marseille, France
| | - Ara Darzi
- Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK
| | - Rajesh Aggarwal
- Department of Surgery and Cancer, St. Mary's Campus, Imperial College Healthcare NHS Trust, London, UK.,Division of Minimally Invasive, Metabolic, and Bariatric Surgery, Department of Surgery, Thomas Jefferson University and Jefferson Health, Philadelphia, USA
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16
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Panshin MS, Alnachoukati OK, Schroeppel TJ, Metzler M, McFann K, Dunn JA. Optimal Duration of Antibiotics Following Appendectomy for Patients With Complicated Appendicitis. Am Surg 2020; 87:480-485. [PMID: 33047976 DOI: 10.1177/0003134820947372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Complicated appendicitis patients typically undergo appendectomy followed by antibiotics. The optimal course of antibiotics for complicated appendicitis is poorly defined. METHODS Data were collected from patients presenting with acute appendicitis and underwent appendectomy at the index hospitalization (2015-2017). Primary outcomes were readmission rate, superficial surgical site infection (SSI), deep space infection (DSI), which includes abscess. Length of post-operative antibiotic use was recorded and an average intent-to-treat (ITT) by operative grade was calculated. RESULTS Two hundred seventy-two patients (23%) were diagnosed with complicated appendicitis. SSI occurred in 4% of patients (n = 11); SSI rates ranged from 0% to 14.6% by ITT group with 3-4 days being the lowest (0%) and <3 days the highest (14.6%) (P = .008). DSI including abscesses occurred in 27 (9.9%) patients; least frequently in the 5-6 day ITT group (7.4%). Length of stay (LOS) was significantly related to longer antibiotic use (P < .001) and increasing operative grade (P < .01). CONCLUSIONS Given the lower incidence of postoperative complications between 3 and 6 days and no added benefit for ITT >6 days, we recommend limiting antibiotic treatment to 3-6 days for all complicated appendicitis cases with additional workup warranted if infectious symptoms persist.
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Affiliation(s)
| | | | | | | | - Kim McFann
- UCHealth Medical Center of the Rockies, Loveland, CO, USA
| | - Julie A Dunn
- UCHealth Medical Center of the Rockies, Loveland, CO, USA
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17
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Antibiotische Therapie bei kritisch kranken Kindern – Ist weniger mehr? Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-01027-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ZusammenfassungDie antibiotische Therapie stellt eine wichtige und in vielen Fällen unverzichtbare Maßnahme zum Erreichen einer Restitutio ad integrum bei bakteriellen Infektionen dar. Hierdurch können auch schwere Infektionen bei immungeschwächten Patienten geheilt werden. Wir wissen heute aber auch, dass insbesondere kritisch kranke Kinder häufig inadäquat antibiotisch behandelt werden – mit ebenfalls potenziell schädlichen Nebenwirkungen. In diesem Spannungsfeld aus kritisch krankem Kind, der Angst, etwas zu verpassen, und potenzieller Übertherapie ist es oft nicht einfach, eine rationale Therapieentscheidung zu fällen. Im vorliegenden Review werden aktuelle Studien zu wichtigen Aspekten der antibiotischen Therapie bei kritisch kranken Kindern beleuchtet und im Hinblick auf klinische Umsetzbarkeit interpretiert. Folgende Teilaspekte werden besprochen: 1) Zeitpunkt der antibiotischen Therapie und Möglichkeiten eines abwartenden Verhaltens, 2) die Auswahl der Antibiotika in der empirischen Therapie, 3) Deeskalationsstrategien und 4) die Dauer der antibiotischen Therapie. Antibiotic-Stewardship-Programme, unter Einbeziehung von pädiatrischen Infektiologen, klinischen Pharmazeuten und Mikrobiologen, spielen bei den häufig schwierigen klinischen Entscheidungen eine entscheidende Rolle.
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18
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Martínez-Pérez A, Payá-Llorente C, Santarrufina-Martínez S, Sebastián-Tomás JC, Martínez-López E, de'Angelis N. Predictors for prolonged length of stay after laparoscopic appendectomy for complicated acute appendicitis in adults. Surg Endosc 2020; 35:3628-3635. [PMID: 32767147 DOI: 10.1007/s00464-020-07841-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/24/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Appendicitis-related hospitalizations linked with peritonitis or postoperative complications result in longer lengths of stay and higher costs. The aim of the present study was to assess the independent association between potential predictors and prolonged hospitalization after laparoscopic appendectomy (LA) for complicated acute appendicitis (CAA). METHODS A retrospective cohort study was conducted on adult patients diagnosed with CAA in which LA was attempted. The primary outcome was a prolonged length of stay (LOS) after surgery, defined as hospitalizations longer than or equal to the 75th percentile for LOS, including the day of discharge. Hierarchical regression models were run to elucidate the independent predictors for the variable of interest. RESULTS The present study involved 160 patients with a mean age of 50.71 years. The conversion rate was 1.9%, and the overall postoperative morbidity rate was 23.8%. The median length of stay (LOS) was 5 days (75th percentile: 7 days). Multivariate analyses included nine variables that are statistically and/or clinically relevant to assess its relationship with a prolonged LOS: three preoperative (age, sex, and comorbidity), four intraoperative (appendix gangrene, perforation, degree of peritonitis, and drain placement), and two postoperative (immediate ICU admission and complications). The development of postoperative complications (OR 6.162, 95% CI 2.451-15.493; p = 0.000) and the placement of an abdominal drain (OR 3.438, 95% CI 1.107-10.683; p = 0.033) were found to be independent predictors for prolonged LOS. For patients not presenting postoperative complications, drain placement was the only independent predictor for the outcome (OR 7.853, 95% CI 1.520-40.558; p = 0.014). Sensitivity analyses showed confirmatory results. CONCLUSION The intraoperative process of care has a clear impact on LOS after LA for CAA in adults; therefore, the decision of whether to drain in these situations should be made more restrictively yet with judicious caution.
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Affiliation(s)
- Aleix Martínez-Pérez
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Avenida Gaspar Aguilar 90, 46017, Valencia, Spain.
| | - Carmen Payá-Llorente
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Avenida Gaspar Aguilar 90, 46017, Valencia, Spain
| | | | - Juan Carlos Sebastián-Tomás
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Avenida Gaspar Aguilar 90, 46017, Valencia, Spain
| | - Elías Martínez-López
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Avenida Gaspar Aguilar 90, 46017, Valencia, Spain
| | - Nicola de'Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery, and Liver Transplantation, Henri-Mondor University Hospital, AP-HP, Université Paris Est - UPEC, Créteil, France
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19
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Sabbagh C, Siembida N, Dupont H, Diouf M, Schmit JL, Boddaert S, Regimbeau JM. The value of post-operative antibiotic therapy after laparoscopic appendectomy for complicated acute appendicitis: a prospective, randomized, double-blinded, placebo-controlled phase III study (ABAP study). Trials 2020; 21:451. [PMID: 32487213 PMCID: PMC7268648 DOI: 10.1186/s13063-020-04411-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 05/14/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Approximately 30% of appendectomies are for complicated acute appendicitis (CAA). With laparoscopy, the main post-operative complication is deep abscesses (12% of cases of CAA, versus 4% for open surgery). A recent cohort study compared short and long courses of postoperative antibiotic therapy in patients with CAA. There was no significant intergroup difference in the post-operative complication rate (12% of organ/space surgical site infection (SSI)). Moreover, antibiotic therapy is increasingly less indicated for other situations (non-complicated appendicitis, post-operative course of cholecystitis, perianal abscess), calling into question whether post-operative antibiotic therapy is required after laparoscopic appendectomy for CAA. METHODS/DESIGN This study is a prospective, multicenter, parallel-group, randomized (1:1), double-blinded, placebo-controlled, phase III non-inferiority study with blind evaluation of the primary efficacy criterion. The primary objective is to evaluate the impact of the absence of post-operative antibiotic therapy on the organ/space surgical site infection (SSI) rate in patients presenting with CAA (other than in cases of generalized peritonitis). Patients in the experimental group will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, a placebo for ceftriaxone (2 g/24 h in one intravenous injection) and a placebo for metronidazole (1500 mg/24 h in three intravenous injections, for 3 days). In the control group, patients will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, antibiotic therapy (ceftriaxone 2 g/24 h and metronidazole 1500 mg/24 h for 3 days). In the event of allergy to ceftriaxone, it will be replaced by levofloxacin (500 mg/24 h in one intravenous injection, for 3 days). The expected organ space SSI rate is 12% in the population of patients with CAA operated on by laparoscopy. With a non-inferiority margin of 5%, a two-sided alpha risk of 5%, a beta risk of 20%, and a loss-to-follow-up rate of 10%, the calculated sample size is 1476 included patients, i.e., 738 per group. Due to three interim analyses at 10%, 25%, and 50% of the planned sample size, the total sample size increases to 1494 patients (747 per arm). TRIAL REGISTRATION Ethical authorization by the Comité de Protection des Personnes and the Agence Nationale de Sécurité du Médicament: ID-RCB 2017-00334-59. Registered on ClinicalTrials.gov (NCT03688295) on 28 September 2018.
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Affiliation(s)
- C Sabbagh
- Department of Digestive Surgery, Amiens University Hospital, Amiens University Medical Center, Avenue Laennec, F-80054, Amiens cedex 01, France.,Jules Verne University of Picardie, Amiens, France.,SSPC (Simplifications des Soins Patients Chirurgicaux Complexes) Research Unit, University of Picardie Jules Verne, Amiens, France
| | - N Siembida
- Department of Digestive Surgery, Amiens University Hospital, Amiens University Medical Center, Avenue Laennec, F-80054, Amiens cedex 01, France.,SSPC (Simplifications des Soins Patients Chirurgicaux Complexes) Research Unit, University of Picardie Jules Verne, Amiens, France
| | - H Dupont
- Jules Verne University of Picardie, Amiens, France.,SSPC (Simplifications des Soins Patients Chirurgicaux Complexes) Research Unit, University of Picardie Jules Verne, Amiens, France.,Intensive Care Unit, Amiens University Medical Center, Amiens, France
| | - M Diouf
- Department of Methodology, Biostatistics, Direction of Clinical Research, Amiens University Medical Center, Amiens, France
| | - J L Schmit
- Jules Verne University of Picardie, Amiens, France.,Department of Infectious Diseases, Amiens University Medical Center, Amiens, France
| | - S Boddaert
- Department of Pharmacology, Amiens University Medical Center, Amiens, France
| | - J M Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens University Medical Center, Avenue Laennec, F-80054, Amiens cedex 01, France. .,Jules Verne University of Picardie, Amiens, France. .,SSPC (Simplifications des Soins Patients Chirurgicaux Complexes) Research Unit, University of Picardie Jules Verne, Amiens, France.
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20
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Fonnes S, Roepstorff S, Holzknecht BJ, Olesen CS, Olsen JHH, Schmidt L, Alder R, Gamborg S, Rasmussen T, Arpi M, Jørgensen LN, Rosenberg J. Shorter Total Length of Stay After Intraperitoneal Fosfomycin, Metronidazole, and Molgramostim for Complicated Appendicitis: A Pivotal Quasi-Randomized Controlled Trial. Front Surg 2020; 7:25. [PMID: 32432123 PMCID: PMC7214811 DOI: 10.3389/fsurg.2020.00025] [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: 03/04/2020] [Accepted: 04/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background: We aimed to investigate the difference in the total length of hospital stay (LOS) after intraperitoneal vs. intravenous antibiotic treatment in patients with complicated appendicitis. Methods: We conducted a quasi-randomized prospective clinical trial. The intervention group received 4 g fosfomycin, 1 g metronidazole, and 50 μg recombinant human granulocyte-macrophage colony-stimulating factor intraperitoneally, which was left in the abdominal cavity, immediately after laparoscopic appendectomy. Postoperatively, this group received antibiotics orally. The control group received intravenous antibiotics both during surgery and postoperatively. We primarily evaluated total LOS within 30 days. Furthermore, we evaluated harms and adverse events, Gastrointestinal Quality of Life Index, postoperative complications, and convalescence. Participants were followed for 30 days postoperatively. Results: A total of 12 participants concluded the trial. The total LOS was significantly shorter in the intervention group (six participants, median 13 h; range 2–21 h) than in the control group (six participants, median 84 h; range 67–169 h), p = 0.017. Comparable harms and Gastrointestinal Quality of Life Index scores were found in the two groups. The time to return to normal activities was median 6 and 10 days for the intervention and the control group, respectively. There were no serious adverse events related to the trial nor any complications in the intervention group. In the control group, two patients developed intraabdominal abscesses. Conclusions: The intervention group had a significantly shorter total LOS. The study was not powered to assess differences in complications, but the results indicate that the intervention seems to be a safe regimen, which can be investigated further to treat patients with complicated appendicitis. Identifiers: EudraCT no. 2017-004753-16. ClinicalTrials:https://clinicaltrials.gov/ct2/show/NCT03435900?term=NCT03435900&draw=2&rank=1">draw=2&rank=1.
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Affiliation(s)
- Siv Fonnes
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Søren Roepstorff
- Digestive Disease Centre, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Barbara Juliane Holzknecht
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Christoffer Skov Olesen
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Joachim Hjalde Halmsted Olsen
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Line Schmidt
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Rasmus Alder
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Sara Gamborg
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Tilde Rasmussen
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Magnus Arpi
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Jacob Rosenberg
- Department of Surgery, Centre for Perioperative Optimisation, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
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21
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Liu Q, Hao F, Chen B, Li L, Liu Q, Guo C. Multi-Center Prospective Study of Restrictive Post-Operative Antibiotic Treatment of Children with Complicated Appendicitis. Surg Infect (Larchmt) 2020; 21:778-783. [PMID: 32150521 DOI: 10.1089/sur.2019.293] [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] [Indexed: 12/17/2022] Open
Abstract
Background: No consensus has been reached regarding the most advantageous duration of antibiotic prophylaxis to decrease post-operative infection complications of appendectomy for acute complex appendicitis. This study aimed to determine the efficacy of short-term antibiotic treatment on post-operative complications in children with complex appendicitis. Methods: A multi-center, parallel group, randomized study was conducted in patients younger than 14 years of age with complicated appendicitis at three hospitals in China. The qualified patients were randomized prospectively to either the restrictive 72-hour short-term antibiotic strategy or the standard antibiotic usage. A comparison of the complications within 24 months, including infectious complications and long-term results, were conducted between the two groups. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR), number ChiCTR1900023941 and is complete. Results: A shorter duration of antibiotic treatment had no effect on intestinal function recovery, antibiotic-associated diarrhea, and health-care-associated Clostridium difficile infection and infectious complication, including intra-abdominal abscess development (17.9% vs. 18.0%, p = 0.52). Furthermore, no substantial difference for re-admission requirement and re-operation were found between the two treatment strategies. A sizeable decrease in total duration of hospitalization (p < 0.001) and average total antibiotic duration (p < 0.001) were observed for the restrictive antibiotic strategy group. Conclusion: In complicated appendicitis, the restrictive antibiotic usage was equivalent to standard antibiotic usage in terms of short- and long-term outcomes, but with shorter hospital stays and fewer antibiotic agents.
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Affiliation(s)
- Qianyang Liu
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Fabao Hao
- Department of Pediatric General Surgery, Qingdao Maternity and Child Care Hospital, Qingdao, P.R. China
| | - Bailin Chen
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Lei Li
- Department of Neonatology, Jinan Maternity and Child Care Hospital, Jinan, P.R. China
| | - Qingshuang Liu
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China.,Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
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Perforated appendicitis: Short duration antibiotics are noninferior to traditional long duration antibiotics. Surgery 2020; 167:475-477. [PMID: 31587914 DOI: 10.1016/j.surg.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/30/2019] [Accepted: 08/07/2019] [Indexed: 01/07/2023]
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Bou Zein Eddine S, Dodgion CM, Qian S, Trevino C, De Moya MA, Yeh DD. Complicated Appendicitis: Are Extended Antibiotics Necessary? A Post Hoc Analysis of the EAST Appendicitis "MUSTANG" Study. J Surg Res 2019; 247:508-513. [PMID: 31812337 DOI: 10.1016/j.jss.2019.09.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/22/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The need for extended postoperative antibiotics (Abx) for complicated (gangrenous or perforated) appendicitis (CA) remains unclear. We hypothesize that giving ≤24 h of Abx for CA is not inferior to a longer duration in preventing infectious complications after appendectomy. METHODS In this post hoc analysis of a prospective multicenter study, only patients with intraoperative diagnosis of CA were included. ANOVA and Chi-squared tests were used to compare length of stay, 30-day readmission rates, surgical site infection (SSI), and intra-abdominal abscess (IAA) between patients receiving ≥96 h and ≤24 h of Abx. RESULTS Of 751 patients with CA, 704 met inclusion criteria. Mean age was 48 (±17) y; 391 (56%) were male. A total of 185 (26%) received Abx for ≤24 h and 100 (14% of overall) received no Abx. 85 (12%) patients were lost to follow-up at 30 d postop. Twenty-seven (4%) patients developed an SSI (≤24 h = 5 (3%), ≥96 h = 22 (5%), P = 0.502) and 82 (13%) developed IAA (≤24 h = 11 (7%), ≥96 h = 71 (15%), P = 0.008) within 30d postop. Sixty-six (11%) patients underwent a secondary intervention for infection within 30 d postop. 41% of SSIs (11/27) and 60% (49/82) of IAA occurred during the index hospitalization. On the multivariate analysis, there was not any evidence of an association between the duration of Abx and an increased rate of SSI (P = 0.539), IAA (P = 0.274), emergency department visits (P = 0.509), readmission (P = 0.911), or secondary interventions (P = 0.523). CONCLUSIONS No evidence of an association between the duration of Abx (≤24 h versus ≥ 96 h) for complicated appendicitis and an increased rate of SSI was observed and ≤24 h duration was associated with shorter length of stay. Because of possible selection bias, adequately powered randomized trials are required to definitely prove noninferiority of shorter course Abx duration.
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Affiliation(s)
- Savo Bou Zein Eddine
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher M Dodgion
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Sinong Qian
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Colleen Trevino
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marc A De Moya
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - D Dante Yeh
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
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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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Contemporary Microbiology and Antimicrobial Treatment of Complicated Appendicitis: The Value of a Short-term Study. Pediatr Infect Dis J 2019; 38:e290-e294. [PMID: 31365479 DOI: 10.1097/inf.0000000000002420] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions to curtail the use of third-generation cephalosporins and antipseudomonal penicillins for the treatment of complicated appendicitis in children are challenging given the tendency to treat complicated disease with broad-spectrum antimicrobials. Reasons for this are unclear, but there is a paucity of contemporary microbiologic data associated with the child presenting with either acute perforated or gangrenous appendicitis. This study aimed to justify the appropriateness of an empiric regimen consisting of ampicillin, tobramycin/gentamicin plus metronidazole and to analyze duration of postoperative therapy. METHODS We conducted a retrospective cohort study from February 1, 2017, to October 31, 2018, in children who underwent appendectomy or interventional radiologic drainage for primary complicated appendicitis. The primary outcome was the proportion of patients who had a pathogen isolated from peritoneal fluid culture that was not susceptible to the recommended empiric therapy. The secondary outcomes were the total duration of antimicrobial therapy and the proportion of patients with a postoperative infectious complication within 30 days after intervention. RESULTS Of 425 children with primary acute appendicitis, 158 (37%) had complicated appendicitis at presentation. Culture was performed in 53 (40%) of the 133 who underwent a surgical or interventional radiologic intervention. The group with peritoneal cultures was more likely to present with longer symptom duration before admission [3 (interquartile range, 2-5) vs 2 (interquartile range, 1-2) days; P < 0.001] and with purulent peritonitis [47% (25/53) vs 13% (10/80); P < 0.001]. The most common pathogens isolated were anaerobes (81%), Escherichia coli (74%) and Streptococcus anginosus group (62%). Only 4% of isolated bacteria were resistant to empiric therapy. Postoperative infectious complications were documented in 23 (17%) patients and were not associated with the presence of a resistant pathogen or the choice of antimicrobial agents but with more severe disease and higher C-reactive protein values (303 vs 83 mg/L; P=0.03) at presentation. CONCLUSIONS In a cohort of previously healthy children presenting with complicated appendicitis requiring surgical drainage, the most common bacteria from peritoneal cultures continue to be S. anginosus, aminoglycoside-susceptible Gram-negative bacilli and anaerobes. In an attempt to reduce extended-spectrum cephalosporin use, these data were useful in supporting the use of metronidazole with ampicillin and an aminoglycoside, rather than third-generation cephalosporins.
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Abstract
Background Data on common practice in the management of patients with complex appendicitis are scarce, especially for the adult population. Variation in the definition of complex appendicitis, indications for and the type of prolonged antibiotic prophylaxis have not been well studied yet. The aim of this study was to document current practice of the classification and postoperative management of complex appendicitis on an international level. Methods An online survey was dispersed among practicing surgeons and surgical residents. Survey questions pertained to the definition of a complex appendicitis, indications for antibiotic prophylaxis after appendectomy, the duration, route of administration and antibiotic agents used. Results A total of 137 survey responses were eligible for analysis. Most respondents were from Northern or Western Europe and were specialized in gastrointestinal surgery. Opinion varied substantially regarding the management of appendicitis, in particular for phlegmonous appendicitis with localized pus, gangrenous appendicitis and iatrogenic rupture of appendicitis. The most common duration of postoperative antibiotics was evenly spread over <3, 3, 5 and 7 days. Whereas most respondents indicated a combined intravenous and oral route of administration was common practice, 28% answered a completely intravenous route of administration was standard practice. Conclusion Current practice patterns in the classification and postoperative management of complex appendicitis are highly variable. Electronic supplementary material The online version of this article (10.1007/s00268-018-4806-4) contains supplementary material, which is available to authorized users.
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McGillen PK, Drake FT, Vallejo A, Brahmbhatt TS, Sanchez SE. Retrospective Analysis of Post-Operative Antibiotics in Complicated Appendicitis. Surg Infect (Larchmt) 2019; 20:359-366. [PMID: 30932747 DOI: 10.1089/sur.2018.223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: There is no consensus regarding the ideal post-operative antibiotic strategy for surgically managed complicated appendicitis. The goal of this study was to investigate different antibiotic regimens used for this purpose at our institution and their association with post-operative outcomes. Methods: The 1,102 patients underwent appendectomy from 2012 to 2016. A detailed chart review was performed on the 188 with complicated appendicitis based on standardized definitions. Descriptive and inferential statistics were used to analyze post-operative antibiotic use and complications. Results: Of the 188 cases of complicated appendicitis, 143 (76%) were classified as perforated by the operative surgeon. These patients were significantly more likely to be started on antibiotics after appendectomy (83.9% versus 33.3%; p < 0.001) and have a greater length of stay (LOS) (p = 0.006). The development of a surgical site infection (SSI) was significantly associated with a clinical diagnosis of diabetes (p = 0.04); the presence of free fluid, abscess, or perforation on pre-operative imaging (p = 0.002, 0.039, and 0.012, respectively); and a decision by the surgeon to leave a drain (p = 0.001). On multiple logistic regression analysis adjusted for free fluid on pre-operative imaging and an intra-operative decision to leave a drain, patients receiving one day or three or more days of antibiotics had higher odds of developing an SSI than patients who did not receive any post-operative antibiotics. Conclusions: In this cohort, operative surgeons accurately identified patients with complicated appendicitis who did not require post-operative antibiotics. For patients deemed to require them, two days of treatment was associated with reduced odds of SSI compared with shorter or longer antibiotic courses. The optimal course of antibiotics remains to be identified, but these findings suggest that longer post-operative courses do not avert SSI compared with two days of antibiotics. A prospective trial could clarify the optimal duration and route of antibiotic therapy in the setting of surgical complicated appendicitis.
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Affiliation(s)
- Patrick K McGillen
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - F Thurston Drake
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Andrew Vallejo
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Tejal S Brahmbhatt
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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Thong DW, Kim J, Dobson B, Cheung H, Arthur T, Anwari T, Archer L, Auld M, Bagguley D, Bhatt J, Bierton C, Bormann S, Bradshaw K, Callahan R, Capati G, Cattanach D, Chai D, Cozier M, Daza F, Martina OD, Dickfos M, Duncan C, Edward L, Elstner K, Franceschini L, Fuller E, Gavey R, Goldman H, Gole H, Harrison E, Honore M, Hughes I, Hwang Y, Jacob M, Jain A, Jones S, Kothapalli A, Kwok M, Lavarack B, Lee L, Liu D, Lonie J, Low N, Mackrill D, Maddern G, McFarlane J, Metcalfe D, Moar X, Morden B, Nabi H, Neo EN, Kin DNY, O'Brien E, O'Donohue P, Paget S, Potent K, Puhalla H, Ramachandran R, Rosley M, Schachtel M, Schmidt A, Sharpe K, Shivananda A, Stupart D, Ta'I S, Theophilus M, Toonsen P, Udovicich C, Van Der Nest B, Walch A, Walker D, Wong E, Wong ZH, Zubair O. Variation in anti‐microbial prescription and complications post emergency appendicectomy in Australia: do we follow recommended guidelines? ANZ J Surg 2019; 90:251-256. [PMID: 30776854 DOI: 10.1111/ans.15099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Da Wei Thong
- Department of SurgeryGold Coast University Hospital Gold Coast Queensland Australia
| | - Jason Kim
- Department of SurgeryGold Coast University Hospital Gold Coast Queensland Australia
| | - Benjamin Dobson
- Department of SurgeryGold Coast University Hospital Gold Coast Queensland Australia
| | - Henry Cheung
- Department of SurgeryGold Coast University Hospital Gold Coast Queensland Australia
| | - Thomas Arthur
- Department of SurgeryGold Coast University Hospital Gold Coast Queensland Australia
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Prospective evaluation of a clinical response directed pathway for complicated appendicitis. J Pediatr Surg 2019; 54:272-275. [PMID: 30528202 DOI: 10.1016/j.jpedsurg.2018.10.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/30/2018] [Indexed: 11/20/2022]
Abstract
AIM Despite evidence to suggest shorter durations of antibiotics are safe in complicated appendicitis, the practice has not been widely adopted in the UK. Our aim was to determine whether a clinical pathway that tailors antibiotics to clinical condition was safe and effective. METHODS A new post-operative pathway (NewPath) was devised that reduced mandatory intravenous antibiotics for complicated appendicitis (perforated or gangrenous) from 5 to 3 days post-operatively, provided the child was apyrexial for >12 h and tolerating oral diet. Oral antibiotics were only given if white-blood-cell counts were raised. Data were collected prospectively (NewPath) and compared to 100 cases immediately prior. Data are presented as median [IQR]. Comparisons used the Fisher's exact or Mann Whitney U tests as appropriate. Significance was defined as p < 0.05. RESULTS One hundred sixty-four children completed the NewPath over 11 months. Age and normal appendicectomy rate were similar [NewPath vs. control, 9y (6-12) vs. 10y (7-13) and 19/164 (12%) vs.15/100 (15%)]. Complicated appendicitis rates were 88/164 [54%] vs. 42/100 [42%]; p = 0.08. Length of stay was shorter for the NewPath [5 (4-7) vs. 7 (6-8) days; p = 0.009], and fewer required oral antibiotics [35/88 (40%) vs. 26/42 (62%); p = 0.01]. Readmissions within 28 days [24/88 (27%) vs. 8/42 (19%), p = 0.39) and intra-abdominal collections [20/88 (23%) vs. 6/42 (14%), p = 0.35] were similar. CONCLUSIONS Post-operative appendicitis care guided by clinical progress and white-blood-cell count can reduce hospital stay and antibiotic use without increasing complications. Pathways such as this could save considerable health resource and contribute to important antimicrobial stewardship initiatives. LEVEL OF EVIDENCE Level III.
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Becker P, Fichtner-Feigl S, Schilling D. Clinical Management of Appendicitis. Visc Med 2018; 34:453-458. [PMID: 30675493 DOI: 10.1159/000494883] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Ever since the first appendectomy has been performed, surgery has been the standard of care for acute appendicitis, with antibiotic therapy being reserved for special situations. Recent studies have shown the feasibility of antibiotic therapy for uncomplicated appendicitis. Methods This clinical therapeutic review is based both on author expertise and a selective literature survey in PubMed based on the term 'appendicitis', combined with the terms 'acute', 'complicated', 'conservative', 'non-operative', 'therapy', 'surgery', and 'strategy'. According to these search results as well as to the treatment guidelines from the American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, European Association of Endoscopic Surgery, and World Society of Emergency Surgery, we present an interdisciplinary treatment concept. Results Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission. The other 10% that fail to respond to antibiotics require a rescue appendectomy. Recurrence rates of non-operated patients within 1 year are as high as 20-30%. Conclusion In uncomplicated appendicitis without risk factors for failure of non-operative management, a shared decision based on the patient's preferences should be made. In cases with risk factors, appendectomy is still the treatment recommended. If the diagnosis is uncertain or clinical symptoms are rather mild, antibiotic therapy should be started. In complicated appendicitis, management depends on the clinical state, with either immediate surgery or primarily antibiotic therapy and combined with drainage of abscess, being followed by interval appendectomy in some cases.
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Affiliation(s)
- Peter Becker
- Medizinische Klinik II, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| | - Stefan Fichtner-Feigl
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg i.Br., Germany
| | - Dieter Schilling
- Medizinische Klinik II, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
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Risk factors for intraabdominal abscess formation after laparoscopic appendectomy - results from the Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study. Wideochir Inne Tech Maloinwazyjne 2018; 14:70-78. [PMID: 30766631 PMCID: PMC6372867 DOI: 10.5114/wiitm.2018.77272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/04/2018] [Indexed: 01/29/2023] Open
Abstract
Introduction According to meta-analyses laparoscopic appendectomy is associated with many benefits. However, in comparison to open surgery an increased rate of intraabdominal abscesses (IAA) has been reported. Identification of predictive factors for this complication may help to identify patients with higher risk of IAA. Aim To identify potential risk factors for intraabdominal abscess after laparoscopic appendectomy (LA). Material and methods Eighteen surgical units in Poland and Germany submitted data of patients undergoing LA to the online web-based database created by the Polish Videosurgery Society of the Association of Polish Surgeons. It comprised 31 elements related to the pre-, intra- and postoperative period. Surgical outcomes were compared among the groups according to occurrence of IAA. Univariate and multivariate logistic regression models were used to identify potential risk factors for IAA. Results 4618 patients were included in the analysis. IAA were found in 51 (1.10%) cases. Although several risk factors were found in univariate analysis, in the multivariate model, only the presence of complicated appendicitis was statistically significant (OR = 2.98, 95% CI: 1.11–8.04). Moreover, IAA has a significant influence on postoperative reintervention rate (OR = 126.95, 95% CI: 67.98–237.06), prolonged length of stay > 8 days (OR = 41.32, 95% CI: 22.86–74.72) and readmission rate (OR = 33.89, 95% CI: 18.60–34.73). Conclusions Intraabdominal abscesses occurs relatively rarely after LA. It is strongly associated with complicated appendicitis. Occurrence of this complication has a great influence on the postoperative period and due to the nature of its treatment is associated with the need for reintervention, prolonged length of stay and by extension possible readmission.
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van den Boom AL, de Wijkerslooth EML, Mauff KAL, Dawson I, van Rossem CC, Toorenvliet BR, Wijnhoven BPL. Interobserver variability in the classification of appendicitis during laparoscopy. Br J Surg 2018; 105:1014-1019. [PMID: 29663311 PMCID: PMC6033013 DOI: 10.1002/bjs.10837] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/27/2017] [Accepted: 01/14/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The intraoperative classification of appendicitis dictates the patient's postoperative management. Prolonged antibiotic prophylaxis is recommended for complex appendicitis (gangrenous, perforated, abscess), whereas preoperative prophylaxis suffices for simple appendicitis. Distinguishing these two conditions can be challenging. The aim of this study was to assess interobserver variability in the classification of appendicitis during laparoscopy. METHODS Short video recordings taken during laparoscopy for suspected appendicitis were shown to surgeons and surgical residents. They were asked to: classify the appendix as indicative of no, simple or complex appendicitis; categorize the appendix as normal, phlegmonous, gangrenous, perforated and/or abscess; and decide whether they would prescribe postoperative antibiotics. Inter-rater reliability was evaluated using Fleiss' κ score and the S* statistic. RESULTS Some 80 assessors participated in the study. Video recordings of 20 patients were used. Interobserver agreement was minimal for both the classification of appendicitis (κ score 0·398, 95 per cent c.i. 0·385 to 0·410) and the decision to prescribe postoperative antibiotic treatment (κ score 0·378, 0·362 to 0·393). Agreement was slightly higher when published criteria were applied (κ score 0·552, 0·537 to 0·568). CONCLUSION There is considerable variability in the intraoperative classification of appendicitis and the decision to prescribe postoperative antibiotic treatment.
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Affiliation(s)
- A. L. van den Boom
- Department of SurgeryErasmus MC – University Medical CentreRotterdamThe Netherlands
| | | | - K. A. L. Mauff
- Department of BiostatisticsErasmus MC – University Medical CentreRotterdamThe Netherlands
| | - I. Dawson
- Department of SurgeryIJsselland ZiekenhuisCapelle a/d IJsselThe Netherlands
| | - C. C. van Rossem
- Department of SurgeryMaasstad ZiekenhuisRotterdamThe Netherlands
| | | | - B. P. L. Wijnhoven
- Department of SurgeryErasmus MC – University Medical CentreRotterdamThe Netherlands
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van den Boom AL, de Wijkerslooth EML, van Rosmalen J, Beverdam FH, Boerma EJG, Boermeester MA, Bosmans JWAM, Burghgraef TA, Consten ECJ, Dawson I, Dekker JWT, Emous M, van Geloven AAW, Go PMNYH, Heijnen LA, Huisman SA, Jean Pierre D, de Jonge J, Kloeze JH, Koopmanschap MA, Langeveld HR, Luyer MDP, Melles DC, Mouton JW, van der Ploeg APT, Poelmann FB, Ponten JEH, van Rossem CC, Schreurs WH, Shapiro J, Steenvoorde P, Toorenvliet BR, Verhelst J, Versteegh HP, Wijnen RMH, Wijnhoven BPL. Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial. Trials 2018; 19:263. [PMID: 29720238 PMCID: PMC5932884 DOI: 10.1186/s13063-018-2629-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022] Open
Abstract
Background Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. Methods Patients of 8 years and older undergoing appendectomy for acute complex appendicitis – defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess – are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed. Discussion This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. Trial registration Dutch Trial Register, NTR6128. Registered on 20 December 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2629-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne Loes van den Boom
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Elisabeth M L de Wijkerslooth
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Marja A Boermeester
- Department of Surgery, Academisch Medisch Centrum, Amsterdam, The Netherlands
| | | | | | | | - Imro Dawson
- Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | | | - Marloes Emous
- Department of Surgery, MC Leeuwarden, Leeuwarden, The Netherlands
| | | | - Peter M N Y H Go
- Department of Surgery, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Luc A Heijnen
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Sander A Huisman
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Joske de Jonge
- Department of Surgery, Tergooi, Hilversum/Blaricum, The Netherlands
| | - Jurian H Kloeze
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marc A Koopmanschap
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Hester R Langeveld
- Department of Pediatric Surgery, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Damian C Melles
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Jeroen E H Ponten
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | | | | | - Joël Shapiro
- Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | - Pascal Steenvoorde
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Joost Verhelst
- Department of Surgery, Ikazia Ziekenhuis, Rotterdam, The Netherlands
| | - Hendt P Versteegh
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Rene M H Wijnen
- Department of Pediatric Surgery, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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Enteral Antibiotics are Non-inferior to Intravenous Antibiotics After Complicated Appendicitis in Adults: A Retrospective Multicentre Non-inferiority Study. World J Surg 2018; 41:2706-2714. [PMID: 28600695 DOI: 10.1007/s00268-017-4076-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Prolonging post-operative antibiotic treatment beyond 3 days does not seem to reduce the incidence of post-operative abscess formation or wound infection after surgery for complicated appendicitis. The route of administration seems to be based on an empirical basis. Using enteral antibiotics could reduce length of stay and reduce overall costs. We aimed to examine whether treatment with enteral antibiotics during the first three post-operative days is non-inferior to intravenous antibiotics regarding intra-abdominal abscess formation or wound infection after surgery for complicated appendicitis. METHODS A retrospective study of adult patients having surgery for complicated appendicitis within a period of 32 months in the Capital Region of Denmark. Primary outcome was the incidence of post-operative abscess formation, and secondary outcome was wound infections, both within 30 days of surgery. Route of antibiotic administration for the first three post-operative days was registered for all patients. RESULTS A total of 1141 patients were included in the study. The overall risk of developing an intra-abdominal abscess was 6.7% (95% CI 5.2%; 8.1%), and the risk of wound infection was 1.2% (95% CI 0.6%; 1.8%). In a multivariate intention-to-treat analysis, patients treated post-operatively with enteral antibiotics had an odds ratio of 0.78 (95% CI 0.41; 1.45, p = 0.429) for developing an intra-abdominal abscess and an odds ratio of 0.86 (95% CI 0.17; 4.29, p = 0.851) for developing a wound infection compared to patients treated post-operatively with intravenous antibiotics. CONCLUSION Treatment with enteral antibiotics was non-inferior compared to treatment with intravenous antibiotics during the first 3 days after surgery for complicated appendicitis.
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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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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: 317] [Impact Index Per Article: 45.3] [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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Xu S, Yu X, Li Y, Shi D, Huang J, Gao Q, Zhang T, Guo S. Analysis of antibiotics selection in patients undergoing appendectomy in a Chinese tertiary care hospital. SPRINGERPLUS 2016; 5:1839. [PMID: 27818877 PMCID: PMC5074929 DOI: 10.1186/s40064-016-3461-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 10/04/2016] [Indexed: 12/17/2022]
Abstract
Background To investigate the status of antibiotics use in acute appendicitis patients who undergo appendectomy in a Chinese tertiary care hospital. Methods A retrospective analysis of 93 patients who underwent appendectomy from June 1, 2011 to May 30, 2012 and had recorded use of intravenous antibiotics. We defined simple appendicitis and suppurative appendicitis as mild appendicitis. Gangrenous appendicitis and perforated appendicitis were classified as advanced appendicitis. The occurrence of advanced appendicitis, postoperative complications and length of hospital stay were the three major end points for outcomes analysis. Results 100 % of the patients received antibiotics therapy before and after operation. 45 patients received Fluoroquinolones (48.4 %), 41 patients received Cephalosporins (44.1 %) and 7 patients received Carbapenems (7.5 %). We found no statistical difference between antibiotics selection and the occurrence of advanced appendicitis (P = 0.3337). Both the monovariate analysis and multivariate analysis showed no statistical difference between antibiotics selection and the postoperative complications (P > 0.05). The average stay of patients receiving Fluoroquinolones was 2.6 days shorter than patients who received Cephalosporins (P = 0.0085). Conclusion It is a lack of a standardized guideline for antibiotics selection in our hospital. All the antibiotics prescription were empirical. We tended to choose high levels of antibiotics, pay insufficient attention to the anaerobic bacteria and have a long duration of antibiotics therapy. We also found that antibiotics selection bore no relationship with the occurrence of advanced appendicitis and postoperative complications. Fluoroquinolones may lead to a shorter hospital stay, but this result may also be affected by the fewer underlying diseases and lower severity of the patients.
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Affiliation(s)
- Shengyong Xu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Xuezhong Yu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Yi Li
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Donglei Shi
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Jingya Huang
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730 China
| | - Qian Gao
- Department of Emergency Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Ting Zhang
- Saint Louis University School of Medicine, Class of 2014, 1042 S. Grand Blvd, Saint Louis, MO 63104 USA
| | - Shigong Guo
- Trauma and Orthopaedic Surgery, Charing Cross Hospital, London, UK
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Gorter RR, Eker HH, Gorter-Stam MAW, Abis GSA, Acharya A, Ankersmit M, Antoniou SA, Arolfo S, Babic B, Boni L, Bruntink M, van Dam DA, Defoort B, Deijen CL, DeLacy FB, Go PM, Harmsen AMK, van den Helder RS, Iordache F, Ket JCF, Muysoms FE, Ozmen MM, Papoulas M, Rhodes M, Straatman J, Tenhagen M, Turrado V, Vereczkei A, Vilallonga R, Deelder JD, Bonjer J. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc 2016; 30:4668-4690. [PMID: 27660247 PMCID: PMC5082605 DOI: 10.1007/s00464-016-5245-7] [Citation(s) in RCA: 218] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/09/2016] [Indexed: 02/08/2023]
Abstract
Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.
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Affiliation(s)
- Ramon R Gorter
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands.
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands.
- Department of Pediatric Surgery, VU University Medical Centre, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Hasan H Eker
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - Gabor S A Abis
- Department of Surgery, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Amish Acharya
- Department of Surgery, St Mary's Hospital, London, UK
| | - Marjolein Ankersmit
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Stavros A Antoniou
- Department of Surgery, Center for Minimally Invasive Surgery, Neuwerk Hospital, Mönchengladbach, Germany
- Department of Surgery, University Hospital of Heraklion, Heraklion, Greece
| | - Simone Arolfo
- Department of Surgery, University of Torino, Torino, Italy
| | - Benjamin Babic
- Department of Surgery, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Luigi Boni
- Department of Surgery, Minimally Invasive Surgery Research Center, University of Insubria, Varese, Italy
| | - Marlieke Bruntink
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | | | - Barbara Defoort
- Department of Surgery, Maria Middelares Ghent, Ghent, Belgium
| | - Charlotte L Deijen
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - F Borja DeLacy
- Department of Surgery, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Peter Mnyh Go
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Florin Iordache
- Department of Surgery, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | | | - Filip E Muysoms
- Department of Surgery, Maria Middelares Ghent, Ghent, Belgium
| | - M Mahir Ozmen
- Department of Surgery, School of Medicine, Bahcesehir University, Istanbul, Turkey
| | - Michail Papoulas
- Department of Surgery, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Michael Rhodes
- Department of Surgery, Stepping Hill Hospital, Stockport, UK
| | - Jennifer Straatman
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Mark Tenhagen
- Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands
| | - Victor Turrado
- Department of Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pecs, Hungary
| | - Ramon Vilallonga
- Department of Surgery, University Hospital Vall Hebrón, Barcelona, Spain
| | - Jort D Deelder
- Department of Surgery, Noordwest Clinics Alkmaar, Alkmaar, The Netherlands
| | - Jaap Bonjer
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
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Bae E, Dehal A, Franz V, Joannides M, Sakis N, Scurlock J, Nguyen P, Hussain F. Postoperative antibiotic use and the incidence of intra-abdominal abscess in the setting of suppurative appendicitis: a retrospective analysis. Am J Surg 2016; 212:1121-1125. [PMID: 27871681 DOI: 10.1016/j.amjsurg.2016.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 09/08/2016] [Accepted: 09/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. METHODS We retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. RESULTS Of 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. CONCLUSIONS The administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use.
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Affiliation(s)
- Esther Bae
- Department of General Surgery, Arrowhead Regional Medical Center/Kaiser Permanente Fontana General Surgery, 400 N Pepper Ave, Colton, CA 92324, USA.
| | - Ahmed Dehal
- John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Vanessa Franz
- Department of General Surgery, Arrowhead Regional Medical Center/Kaiser Permanente Fontana General Surgery, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Michael Joannides
- LSU Heath Sciences Center-New Orleans, General Surgery, New Orleans, LA, USA
| | - Nicholas Sakis
- Arrowhead Regional Medical Center, Department of Internal Medicine, Colton, CA, USA
| | - Joshua Scurlock
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Patrick Nguyen
- Department of General and Colorectal Surgery, Kaiser Permanente SCPMG, Fontana, CA, USA
| | - Farabi Hussain
- Arrowhead Regional Medical Center, Department of General Surgery, Colton, CA, USA
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Giesen LJ, van den Boom AL, van Rossem CC, den Hoed P, Wijnhoven BP. Retrospective Multicenter Study on Risk Factors for Surgical Site Infections after Appendectomy for Acute Appendicitis. Dig Surg 2016; 34:103-107. [PMID: 27631081 PMCID: PMC5296882 DOI: 10.1159/000447647] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/13/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical site infections (SSI) are seen in up to 5% of patients after appendectomy for acute appendicitis. SSI are associated with prolonged hospital stay and increased costs. The aim of this multicenter study was to identify factors associated with SSI after appendectomy for acute appendicitis. METHODS Patients who underwent appendectomy for acute appendicitis between June 2014 and January 2015 in 6 teaching hospitals in the southwest of the Netherlands were included. Patient, diagnostic, intra-operative and disease-related factors were collected from the patients' charts. Primary outcome was surgical site infection. Multivariable logistic regression was performed to identify independent risk factors for SSI. RESULTS Some 637 patients were included. Forty-two patients developed a SSI. In univariable analysis body temperature >38°C, CRP>65 and complex appendicitis were associated with SSI. After multivariable logistic regression with stepwise backwards elimination, complex appendicitis was significantly associated with SSI (OR 4.09; 95% CI 2.04-8.20). Appendiceal stump closure with a stapler device was inversely correlated with SSI (OR 0.40; 95% CI 0.24-0.97) Conclusions: Complex appendicitis is a risk factor for SSI and warrants close monitoring postoperatively. The use of a stapler device for appendiceal stump closure is associated with a reduced risk of SSI.
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Affiliation(s)
- Louis J.X. Giesen
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - P.T. den Hoed
- Department of Surgery, Ikazia Hospital, Rotterdam, The Netherlands
| | - Bas P.L. Wijnhoven
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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Lasheen AE, Abd Elaziz O, Elaal SA, Alkilany M, Sieda B, Alnaimy T. Surgical Wound Infections After Laparoscopic Appendectomy With or Without Using Reusable Retrieval Bag: A Retrospective Study. JOURNAL OF MINIMALLY INVASIVE SURGICAL SCIENCES 2016; 5. [DOI: 10.17795/minsurgery-36894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Gomes CA, Sartelli M, Di Saverio S, Ansaloni L, Catena F, Coccolini F, Inaba K, Demetriades D, Gomes FC, Gomes CC. Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and laparoscopic findings. World J Emerg Surg 2015; 10:60. [PMID: 26640515 PMCID: PMC4669630 DOI: 10.1186/s13017-015-0053-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/24/2015] [Indexed: 12/29/2022] Open
Abstract
Advances in the technology and improved access to imaging modalities such as Computed Tomography and laparoscopy have changed the contemporary diagnostic and management of acute appendicitis. Complicated appendicitis (phlegmon, abscess and/ or diffuse peritonitis), is now reliably distinguished from uncomplicated cases. Therefore, a new comprehensive grading system for acute appendicitis is necessary. The goal is review and update the laparoscopic grading system of acute appendicitis and to provide a new standardized classification system to allow more uniform patient stratification. During the last World Society of Emergency Surgery Congress in Israel (July, 2015), a panel involving Acute Appendicitis Experts and the author’s discussed many current aspects about the acute appendicitis between then, it will be submitted a new comprehensive disease grading system. It was idealized based on three aspect of the disease (clinical and imaging presentation and laparoscopic findings). The new grading system may provide a standardized system to allow more uniform patient stratification for appendicitis research. In addition, may aid in determining optimal management according to grade. Lastly, what we want is to draw a multicenter observational study within the World Society of Emergency Surgery (WSES) based on this design.
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Affiliation(s)
- Carlos Augusto Gomes
- Surgery Department, Therezinha de Jesus University Hospital, Medical and Health Science School, Surgery Unit, Federal University of Juiz de Fora (UFJF), Rua Senador Salgado Filho 510 / 1002, Bairro Bom Pastor, Juiz de Fora, Minas Gerais 36021-660 Brasil
| | | | | | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | | | - Kenji Inaba
- University of California, San Francisco, USA
| | - Demetrios Demetriades
- University of California, San Francisco, USA ; Department of Surgery (K.I.), Keck School of Medicine of University of Southern California, Los Angeles, CA USA
| | - Felipe Couto Gomes
- Internal Medicine Departament, Therezinha de Jesus University Hospital, Medical and Health Science School, Juiz de Fora, Brazil
| | - Camila Couto Gomes
- Internal Medicine Departament, Monte Sinai Hospital, Juiz de Fora, Minas Gerais Brazil
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Kim DY, Nassiri N, Saltzman DJ, Ferebee MP, Macqueen IT, Hamilton C, Alipour H, Kaji AH, Moazzez A, Plurad DS, de Virgilio C. Postoperative antibiotics are not associated with decreased wound complications among patients undergoing appendectomy for complicated appendicitis. Am J Surg 2015; 210:983-7; discussion 987-9. [PMID: 26453292 DOI: 10.1016/j.amjsurg.2015.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/02/2015] [Accepted: 07/16/2015] [Indexed: 01/03/2023]
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Sartelli M, Catena F, Ansaloni L, Coccolini F, Di Saverio S, Griffiths EA. Duration of Antimicrobial Therapy in Treating Complicated Intra-Abdominal Infections: A Comprehensive Review. Surg Infect (Larchmt) 2015; 17:9-12. [PMID: 26468904 DOI: 10.1089/sur.2015.130] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Surgeons managing intra-abdominal infections should always respect the basic principles of antibiotic treatment. An adequate duration of antimicrobial therapy is important to optimize empiric therapy and minimize selective pressures favoring antimicrobial resistance. METHODS The optimal duration of antibiotic therapy for intra-abdominal infections (IAIs) has been debated in the last years. A literature research, based on PubMed database and limited to English language publications, was performed without restriction of time or type of manuscript. RESULTS In stable patients a short course of antimicrobial therapy (3-5 d) after adequate source control, depending on fever and leukocytosis, may be a reasonable option. In critically ill patients with severe sepsis and septic shock, an individualized approach is always mandatory and patient's inflammatory response should be monitored regularly. Procalcitonin may be helpful for guiding antibiotic treatment in critically ill surgical patients and in predicting treatment response. CONCLUSIONS General surgeons managing intra-abdominal infections should always respect the basic principles of antibiotic treatment. Duration of antimicrobial treatment is an important variable to evaluate in treating complicated intra-abdominal infections.
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Affiliation(s)
| | - Fausto Catena
- 2 Emergency Surgery Department, Maggiore Parma Hospital , Parma, Italy
| | - Luca Ansaloni
- 3 General Surgery Department, Papa Giovanna XXIII Hospital , Bergamo, Italy
| | - Federico Coccolini
- 3 General Surgery Department, Papa Giovanna XXIII Hospital , Bergamo, Italy
| | | | - Ewen A Griffiths
- 5 Department of Surgery, Queen Elizabeth Hospital , Birmingham, United Kingdom
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Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386:1278-1287. [PMID: 26460662 DOI: 10.1016/s0140-6736(15)00275-5] [Citation(s) in RCA: 575] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
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Affiliation(s)
- Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Salomone Di Saverio
- Emergency and General Surgery Department, CA Pizzardi Maggiore Hospital, Bologna, Italy
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Affiliation(s)
- Daniel E Levin
- Department of General Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Walter Pegoli
- Department of General Surgery, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Dunkel B, Johns IC. Antimicrobial use in critically ill horses. J Vet Emerg Crit Care (San Antonio) 2015; 25:89-100. [PMID: 25582245 DOI: 10.1111/vec.12275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 09/15/2014] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To discuss controversies surrounding antimicrobial use in critically ill horses. DATA SOURCES PubMed searches from 1970-present for terms including, but not limited to: "horse," "foal," "antimicrobial," "prophylaxis," "infection," "surgery," "sepsis," and "antimicrobial resistance." HUMAN DATA SYNTHESIS Increasing bacterial antimicrobial resistance has changed first-line antimicrobial choices and prompted shortening of the duration of prophylactic and therapeutic treatment. The need to decrease bacterial resistance development to critically important antimicrobials has been highlighted. VETERINARY DATA SYNTHESIS Veterinary medicine has followed a similar trend but often without a high-level evidence. Common dilemmas include diseases in which the theoretically most effective drug is a reserved antimicrobial, the inability to differentiate infectious from noninfectious disease, the duration and necessity of prophylactic antimicrobials and use of antimicrobials in primary gastrointestinal disease. These problems are illustrated using examples of purulent infections, neonatal sepsis, colic surgery, and treatment of colitis. Although enrofloxacin, cephalosporins, and doxycycline, in contrast to gentamicin, reach therapeutic concentrations within the lungs of healthy horses, the first two should not be used as first line treatment due to their reserved status. Due to the high risk of bacterial sepsis, antimicrobial treatment remains indispensable in compromised neonatal foals but shortening the length of antimicrobial treatment might be prudent. One prospective randomized study demonstrated no difference between 3 and 5 days of perioperative antimicrobial treatment in colic surgery but shorter durations were not evaluated. High-level evidence to recommend antimicrobial treatment of adult horses with undifferentiated diarrhea does not exist. CONCLUSIONS Few evidence-based recommendations can be made. Commonly used antimicrobial combinations remain the mainstay for treating purulent infections. Antimicrobial treatment for compromised foals should not extend beyond recovery. Continuation of prophylactic antimicrobials >3 days is likely unnecessary after colic surgery; shorter durations might be equally effective. Antimicrobial prophylaxis in adult horses with diarrhea is unlikely to be beneficial.
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Affiliation(s)
- Bettina Dunkel
- Department of Clinical Science and Services, The Royal Veterinary College, North Mymms, Hatfield, Hertforshire, United Kingdom, United Kingdom
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Xiao Y, Shi G, Zhang J, Cao JG, Liu LJ, Chen TH, Li ZZ, Wang H, Zhang H, Lin ZF, Lu JH, Yang T. Surgical site infection after laparoscopic and open appendectomy: a multicenter large consecutive cohort study. Surg Endosc 2014; 29:1384-93. [PMID: 25303904 DOI: 10.1007/s00464-014-3809-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 08/11/2014] [Indexed: 12/31/2022]
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