Acute appendicitis: efficacy of prophylactic preoperative antibiotics in the reduction of septic morbidity

Open appendectomy for pediatric ruptured appendicitis: a historical clinical review of the prophylaxis of wound infection and postoperative intra-abdominal abscess

BACKGROUND

We conducted a 3-decade clinical review of prophylaxis for wound infection and postoperative intra-abdominal abscess after open appendectomy for pediatric ruptured appendicitis.

METHODS

We reviewed the charts of patients with ruptured appendicitis who underwent open appendectomy performed by the same pediatric surgeon at the Hospital for Sick Children, Toronto, Canada, between 1969 and 2003, inclusive. We evaluated 3 types of prophylaxis: subcutaneous (SC) antibiotic powder, peritoneal wound drain and intravenous (IV) antibiotics. We divided the sample into 4 treatment groups: peritoneal wound drain alone (group 1); peritoneal wound drain, SC antibiotic powder and IV antibiotics (group 2); SC antibiotic powder and IV antibiotics (group 3); and IV antibiotics alone (group 4). We used the χ(2) test with Bonferroni correction for multiple comparisons.

RESULTS

There were 496 patients: 348 (70%) boys and 148 (30%) girls, with a mean age of 7 (range newborn to 17) years. There were 90 (18%) wound infections. Compared with the current standard of practice, IV antibiotics alone (group 4), peritoneal wound drain (group 1) was associated with the lowest number of wound infections (7 [7%], p = 0.023). There were 43 (9%) postoperative intra-abdominal abscesses. Compared with IV antibiotics alone, SC antibiotic powder with IV antibiotics (group 3) was associated with the lowest number of postoperative intra-abdominal abscesses (14 [6%], p = 0.06).

CONCLUSION

Over a 35-year period of open appendectomy for pediatric ruptured appendicitis, wound infection was least frequent in patients who received prophylactic peritoneal wound drain, and postoperative intra-abdominal abscess was least frequent in those who received prophylactic SC antibiotic powder and IV antibiotics.

Oral metronidazole as antibiotic prophylaxis for patients with nonperforated appendicitis

Background

The rate of wound infection after appendectomy without antibiotic prophylaxis is 10%–30%. The role of prophylactic antibiotic therapy in nonperforated appendicitis is still controversial. Metronidazole is against anaerobic organisms and its bioavailability after oral and parenteral administration has been shown to be similar. The objective of the present study is to compare the infective complications rate after open appendectomy for nonperforated appendicitis receiving either oral or intravenous metronidazole as prophylaxis.

Methods and Materials

From June 2007 to July 2009 in a randomized controlled trial, 204 patients with nonperforated appendicitis underwent an open appendectomy; 122 male and 82 female with mean age of 25 years. Among these, 102 (case group) received oral metronidazole and in 102 (control group) metronidazole was administered intravenously before surgery. The rate of wound infection and duration of the postoperative hospital stay was studied in the two groups.

Results

The rate of wound infection was not significantly different in the two groups. (6% and 4% in study and control group, respectively, P = 0.861). Also the hospital stay was equal in two groups (2.3 days and 2.7 days in study and control group, respectively, P = 0.293).

Conclusion

Single dose of oral metronidazole prior to operation can provide a sufficient prophylaxis for nonperforated appendicitis; so, it can be substitute the parental route of antibiotic administration.

Wound infection prophylaxis in pediatric acute appendicitis: a 26-year prospective study

PURPOSE

The purpose of this study was to determine the best wound infection prophylaxis in pediatric acute appendicitis.

METHODS

From 1969 to 1995 inclusive, 453 consecutive pediatric patients at the same children's hospital had an appendix with acute inflammation (acute appendicitis) removed by the same staff surgeon and his resident. The stump was not inverted, and chromic catgut was used throughout. No intraperitoneal antibiotics, irrigation, or drains were used, and the skin closure was with silk sutures initially and then with staples since 1986. The infants and children were divided into 6 consecutive groups of 52 to 96 patients, with each group lasting 2 to 5 years. The wound treatment groups were as follows: no treatment, drain or pack, drain or pack plus antibiotic powder, antibiotic powder, preoperative intravenous antibiotic plus antibiotic powder, and preoperative intravenous antibiotic. The wound Penrose drain, one half-inch gauze pack, and/or antibiotic powder (ampicillin, 1977-1981; cefoxitin, 1982-1995) were all placed in the subcutaneous space.

RESULTS

There were a total of 50 (11%) wound infections (pus) that occurred between 4 and 40 days when no antibiotic powder was used and 2 to 14 days with antibiotic powder. In all 6 groups of patients, no organism was grown in most (80%) infections and Escherichia coli was the second commonest (12%). The serous ooze, which occurred only with the use of antibiotic powder (8%), was seen between 6 and 18 days, and no organism was ever cultured.

CONCLUSIONS

The patients with preoperative (or intraoperative) intravenous antibiotics (cefoxitin) plus wound antibiotic powder (cefoxitin) had the lowest infection rate (2.5%). When this group was compared with the baseline group 1 (no treatment), it was the only group in which wound treatment made a significant difference (P = .003).

Intraincisional antibiotic in addition to systemic antibiotic treatment fails to reduce wound infection rates in contaminated abdominal surgery. A controlled clinical trial

One hundred ninety patients with peritonitis at the time of abdominal surgery were allocated at random to systemic antibiotic treatment alone or systemic antibiotic treatment combined with topical application of antibiotics in the wound at the time of wound closure. The overall wound infection rate was 17 percent without significant difference between the two treatment groups (P greater than 0.80).

Randomized, prospective, and double-blind trial of new beta-lactams in the treatment of appendicitis

A prospective, randomized, and double-blind study was conducted with 864 patients operated on for appendicitis. In early cases, including normal and acute appendicitis, one dose of antibiotic was given. The rate of postappendectomy septic complications in patients who received cefotaxime, cefoperazone, or moxalactam was very low (about 3%), and there was no statistical difference between the drugs. For late cases, including gangrenous and perforated appendicitis, the antibiotics were continued for 5 days. Moxalactam decreased significantly the septic complications in these patients when compared with the other two drugs. It is safe, free from serious toxic side effects, and more convenient and easier to administer than combination antibiotic therapy. The main disadvantage of moxalactam is its high cost, but this has to be balanced against the savings in nursing time, the cost of monitoring renal function and serum level when aminoglycosides are used, and the reduced usage and manipulation of infusion sets.

Surgical antimicrobial prophylaxis: principles and guidelines

Antimicrobial prophylaxis for surgical procedures is an area that is recognized as being subject to individual clinical variations. This review gives practitioners some basic principles of rational prophylaxis as defined by the medical literature. In addition, this literature is evaluated and condensed to provide clinicians with guidelines for particular procedures: obstetric, gynecologic, gastric, biliary, colonic, urologic, cardiac, thoracic, vascular, orthopedic and head and neck. Each section concludes with recommendations for the clinically most accepted prophylactic regimens. Antibiotics discussed include not only the older agents, but where good information exists, the newer cephalosporins. The suggested regimens consider efficacy, safety and cost as determinants in rational prescribing. Although research into even shorter, and perhaps more cost-effective, regimens continues, this compilation lists state-of-the-art recommendations.

The prophylactic use of antimicrobials in surgery

During the period August 1976 to June 1982, there were 98 reports of antimicrobial prophylaxis in human surgery that were judged unevaluable. Our review, coupled with that of Chodak and Plaut, identified studies of 126 antibiotic regimens that were considered evaluable and a total of 205 studies considered unevaluable. A decrease in infection rate in antibiotic-treated patients compared to non-antibiotic-treated patients was seen in 120 (95%) of the evaluable regimens. Ninety-nine (79%) of these 120 regimens produced statistically significant reductions in the infection rate (P less than .05, chi 2 analysis). The majority of the antibiotic regimens were tested in procedures that were classified as clean-contaminated. Of the regimens that yielded a statistically significant reduction in infection rate with antimicrobial therapy, in 66 (67%) the agents were used for 24 hours or less. Five regimens were identified in which a higher infection rate occurred in specific patient groups when prophylactic antibiotics were used, but the differences were not statistically significant. In the overwhelming majority of evaluable studies, antibiotics decreased the incidence of surgical infection compared with non-antibiotic groups. The available data also support the effectiveness of short prophylactic antibiotic courses of 24 hours' duration or less. The duration necessary for antibiotic prophylaxis was specifically tested in nine regimens. In all nine, a short course (less than 24 hours) of antibiotic prophylaxis was as effective as longer periods of therapy (24 hours to 5 days) in preventing infection.

Rational use of antibiotics for perforated appendicitis in childhood

Gangrenous and perforated appendicitis was reviewed in 300 pediatric patients. Those with only gangrene generally had a benign course regardless of whether antibiotic therapy was used. However, patients with local perforation or generalized peritonitis had a high incidence of infective complications if they were not treated with antibiotics. Children treated with ampicillin, gentamicin, and clindamycin had markedly fewer wound infections and abscesses and were able to tolerate a diet and go home sooner than those receiving ampicillin and/or gentamicin.

Effect of prophylactic antibiotics in acute nonperforated appendicitis: a prospective, randomized, double-blind clinical study

A prospective, randomized, double-blind clinical study was performed to determined the efficacy of short-term (24 hr) perioperative antibiotics in preventing septic complications after emergency appendectomy for nonperforated appendicitis. The patients were stratified into three clinical arms: Group I (placebo, n = 45), Group II (cefamandole, n = 46) and Group III (cefamandole plus carbenicillin, n = 45). The three groups of patients were similar in regard to age, sex, duration of operation and pathologic classification of the appendix. The overall incidence of infection in the study was 5.1%. The infection rates in Groups II (2.2%) and III (0%) were significantly lower than Group I (placebo) (13.3%), (p less than 0.05). No difference was observed between cefamandole alone and cefamandole plus carbenicillin. Average postoperative hospital days per patient for each group was: Group I - 3.8 days; Group II - 2.9 days; Group III - 3.1 days. Cost analysis of hospitalization including cost of prophylactic antibiotics revealed a $247.99 per patient saving for Group II versus Group I and $95.53 for Group III versus Group I. Systemic prophylactic antibiotics can successfully reduce septic complications after appendectomy for nonperforated appendicitis, and a single drug (cefamandole) directed at the facultative pathogens is as effective as double drug therapy, which includes specific anaerobic coverage.

Prophylaxis of infection after appendicectomy: a survey of current surgical practice

Two hundred and eighty questionnaires were sent to junior surgical staff throughout England inquiring about their use of systemic antibiotic prophylaxis, topical antibacterial agents, and surgical drainage in appendicectomy. One hundred and seventy-five (63%) replies were received from 81 of the 87 hospitals included in the survey. Prophylactic systemic antibiotics were used by 78 surgeons (46%) when operating on a normal appendix but by 168 (99%) when the organ had perforated. Most surgeons started antibiotics before operation, but proportionately fewer did so when the appendix was gangrenous or perforated. Patients with severe contamination tended to receive longer courses of antibiotics, although the duration of administration varied considerably. Metronidazole was included in over 95% of all the prophylactic regimens and was often combined with other drugs when the appendix was gangrenous and perforated. Topical antibacterial agents were applied to the wound routinely by only 45 surgeons (26%), although 106 (61%) used them sometimes. Povidone-iodine was the agent most commonly used. Only 98 surgeons (56%) ever drained appendicectomy wounds, while 135 (77%) sometimes drained the peritoneal cavity. Evidence suggests that present methods of giving systemic antibiotic prophylaxis should continue, but that topical agents and surgical drainage are perhaps unnecessary when surgeons are confident of the efficacy of the systemic treatment used.

Discriminate use of antibiotic prophylaxis in gastroduodenal surgery

In a prospective study of 107 patients undergoing surgery for gastroduodenal disease, antibiotics were withheld from a group of 24 patients defined preoperatively to be at low risk of developing postoperative infections; no wound infection occurred in this group. Perioperative cephaloridine was randomized among the remaining patients (high risk). Wound infections developed in 11 of 42 patients who did not receive cephaloridine, but in none of the 41 patients who were given cephaloridine (p less than 0.02). Coliform bacteria were grown only from swabs of the stomach mucosa of patients in the high risk group and were the main cause of wound infections. Severe preoperative lymphocytopenia was frequently associated with the development of serious postoperative sepsis. The results validate a policy of restricting antibiotic prophylaxis in gastroduodenal operations to patients at high risk of postoperative infection and suggest a new risk factor--the preoperative blood lymphocyte count.