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Bhaskar K, Clarke S, Moore LSP, Hughes S. Bacterial peritonitis in paediatric appendicitis; microbial epidemiology and antimicrobial management. Ann Clin Microbiol Antimicrob 2023; 22:45. [PMID: 37270568 DOI: 10.1186/s12941-023-00591-1] [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: 02/06/2023] [Accepted: 04/27/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Appendicitis remains a common surgical emergency in children. Empirical antibacterial treatment is indicated to reduce infective complications. We investigate the bacterial pathogens identified intra-operatively during appendectomies in children to guide empirical surgical antimicrobial prophylaxis options. METHODS A retrospective analysis of patients (< 18 years old) undergoing an appendectomy across a multisite London hospital (Nov 2019-March 2022) was undertaken. Patient-related outcomes including length of hospital stay (LOS), days of antibacterial therapy (DOT), intra-operative microbiology and post-operative radiology reports were interrogated. RESULTS 304 patients underwent an appendectomy during this period; 39.1% of patients had intraoperative samples cultured. Bacterial pathogens were found in 73/119 (61.3%) cases; the most common isolates being Escherichia coli (42.0%), Pseudomonas aeruginosa (21.0%), milleri Streptococcus spp. (14.3%) and Bacteroides fragilis (5.9%). Polymicrobial infection was common (32/73). Isolation of Pseudomonas spp. from intra-operative sampling was associated with a greater LOS (7.0 vs. 5.0 days; p = 0.011) but nil effect on the incidence of postoperative collections. Presence of milleri Streptococcus spp. was associated with longer LOS (7.0 vs. 5.0 day; p = 0.007), DOT (12.0 vs. 8.5 day; p = 0.007) but had no observed outcome on postoperative collections (29.4% vs. 18.6%; p = 0.330). 48% of E. coli positive cultures were co-amoxiclav resistant and prolonged LOS compared to the non-resistant group (7.0 vs. 5.0 days; p = 0.040) but had no difference in post-operative collections (29.2% vs. 17.9%; p = 0.260). CONCLUSION A high proportion of children with appendicitis have Pseudomonas spp. isolated, leading to a prolonged LOS. Evolving Enterobacterales resistance and the presence of Pseudomonas spp. necessitate extended antibacterial coverage for paediatric appendectomies with evidence of peritonitis.
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Affiliation(s)
- Keir Bhaskar
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
- Department of Medicine, Imperial College London, Exhibition Road, South Kensington, London, SW7 2BX, England, UK
| | - Simon Clarke
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Luke S P Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
- Department of Medicine, Imperial College London, Exhibition Road, South Kensington, London, SW7 2BX, England, UK.
| | - Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
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Tamura R, Nakamura K, Hirotani T, Yasui Y, Okajima H. Differences in isolated bacteria between perforated and non-perforated appendicitis: an analysis of 680 consecutive appendicectomies in a single institution. Pediatr Surg Int 2022; 38:1887-1893. [PMID: 36125545 DOI: 10.1007/s00383-022-05236-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Escherichia coli and Bacteroides species are the most frequently detected species in ascites in perforated appendicitis and are generally sensitive to non-empiric cephalosporins like cefazolin or cefmetazole. However, monotherapy with such antibiotics is mostly insufficient for perforated appendicitis. To investigate this issue, this study aimed to compare bacterial floras in ascites culture between perforated and non-perforated appendicitis. METHODS Ascites culture results in perforated and non-perforated appendicitis cases were analyzed using a departmental database. The duration of symptoms before surgery, pre-surgical white blood cell count, C-reactive protein value, postsurgical length of stay, length of antibiotic treatment, and the rate of using second-line antibiotics or complications were also compared. RESULTS A total of 608 and 72 cases of non-perforated and perforated appendicitis were included. Escherichia coli and Bacteroides species were the dominant bacteria in both conditions. However, the total proportions of Pseudomonas aeruginosa, Streptococcus anginosus group, and Enterococcus group were significantly higher in perforated appendicitis than in non-perforated appendicitis. CONCLUSION Pseudomonas aeruginosa, Streptococcus anginosus group, and Enterococcus group have better susceptibility to penicillin-based empiric antibiotics than cephalosporins. The abundance of these bacteria might explain why non-empiric cephalosporins are not effective in perforated appendicitis and the superiority of penicillin-based empiric antibiotics.
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Affiliation(s)
- Ryo Tamura
- Department of Pediatric Surgery, Kanazawa Medical University, Daigaku 1-1, Uchinada, Kahoku, Ishikawa, 9200293, Japan.
| | - Kiyokuni Nakamura
- Department of Pediatric Surgery, Kanazawa Medical University, Daigaku 1-1, Uchinada, Kahoku, Ishikawa, 9200293, Japan
| | - Taichi Hirotani
- Department of Pediatric Surgery, Kanazawa Medical University, Daigaku 1-1, Uchinada, Kahoku, Ishikawa, 9200293, Japan
| | - Yoshitomo Yasui
- Department of Pediatric Surgery, Kanazawa Medical University, Daigaku 1-1, Uchinada, Kahoku, Ishikawa, 9200293, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Daigaku 1-1, Uchinada, Kahoku, Ishikawa, 9200293, Japan
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Cimpean S, Barranquero AG, Surdeanu I, Cadiere B, Cadiere GB. Implications of bacteriological study in complicated and uncomplicated acute appendicitis. Ann Coloproctol 2022:ac.2022.00157.0022. [PMID: 36353816 DOI: 10.3393/ac.2022.00157.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/07/2022] [Indexed: 11/11/2022] Open
Abstract
Purpose Bacteriological sample in the presence of intraabdominal free fluid is necessary to adapt the antibiotherapy and to prevent the development of resistance. The aim was to evaluate the differences between uncomplicated (UAA) and complicated acute appendicitis (CAA) in terms of bacterial culture results and antibiotic resistance, and to evaluate the factors linked with CAA. Methods We performed a single-center, retrospective observational study of all consecutive patients who presented with appendicular peritonitis and underwent emergent surgery in a tertiary referral hospital in Brussels, Belgium, between January 2013 and December 2020. The medical history, parameters at admission, bacterial culture, antibiotic resistance, and postoperative outcomes of 268 patients were analyzed. UAA was considered catarrhal or phlegmonous inflammation of the appendix. CAA was considered gangrenous or perforated appendicitis. Results Positive microbiological cultures were significantly higher in the CAA group (68.2% vs. 53.4%). The most frequently isolated bacteria in UAA and CAA cultures were Escherichia coli (37.9% and 48.6%). Most observed resistances were against ampicillin (28.9% and 21.7%) and amoxicillin/clavulanic acid (16.4% and 10.5%) in UAA and CAA, respectively. A higher Charlson comorbidity index, an elevated white blood cell count, an open procedure, and the need for drainage were linked to CAA. Culture results, group of bacterial isolation, and most common isolated bacteria were not related to CAA. Conclusion CAA presented a higher rate of positive cultures with increased identification of gram-negative bacteria. Bacterial culture from the peritoneal liquid does not reveal relevant differences in terms of antibiotic resistance.
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Affiliation(s)
- Sorin Cimpean
- Royal Belgian Society for Surgery, Brussels, Belgium
- Departement of General and Digestive Surgery, Iris Hospitals South, Brussels, Belgium
| | | | - Ion Surdeanu
- Departement of General and Digestive Surgery, Iris Hospitals South, Brussels, Belgium
| | - Benjamin Cadiere
- Departement of Surgery, Saint Pierre University Hospital, Brussels, Belgium
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Tocu G, Tutunaru D, Mihailov R, Serban C, Dimofte F, Niculet E, Tatu AL, Firescu D. Particularities of diagnosis in an elderly patient with neglected peritonitis: a case report. J Int Med Res 2022; 50:3000605221118705. [PMID: 36003024 PMCID: PMC9421225 DOI: 10.1177/03000605221118705] [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] [Indexed: 11/24/2022] Open
Abstract
Acute peritonitis accounts for 1% of inpatient surgical emergencies and is the second
leading cause of sepsis in patients in intensive care departments. Diagnosis through
laboratory analysis in bacterial peritonitis focuses mainly on the biomarkers,
procalcitonin and C-reactive protein. A 73-year-old male patient presented with meteorism,
diarrhea, vomiting, fever, and hypotension. Laboratory investigations showed very high
procalcitonin and C-reactive protein values, and abdominal radiography revealed
paraumbilical hydroaerial levels, which suggested septic shock of intra-abdominal origin.
Emergency laparotomy was performed, which revealed agglutinated intestinal loops in the
right iliac fossa with false membranes, purulent fluid, overdistended jejunum and ileum
with an occlusive appearance, acute gangrenous appendicitis with perforation, and
suppurative omentitis. The intraoperative diagnosis was acute neglected peritonitis in the
occlusive phase owing to acute gangrenous appendicitis with perforation and suppurative
omentitis. Laboratory analysis in conjunction with imaging provides important information
in the early diagnosis of infectious pathology in elderly patients, even if these methods
do not accurately identify the cause. The combination of procalcitonin and C-reactive
protein biomarker levels successfully contributed to the diagnosis in this case. Notably,
the patient’s white blood cell counts were inconsistent with the severity of the
infection.
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Affiliation(s)
- George Tocu
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of Laboratory Medical Analysis, Sfantul Apostol Andrei Emergency County Hospital, Galati, Romania
| | - Dana Tutunaru
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of Laboratory Medical Analysis, Sfantul Apostol Andrei Emergency County Hospital, Galati, Romania
| | - Raul Mihailov
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of General Surgery, Sfantul Apostol Andrei Emergency County Hospital, Galati, Romania
| | - Cristina Serban
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of General Surgery, Sfantul Apostol Andrei Emergency County Hospital, Galati, Romania
| | - Florentin Dimofte
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of Orthopaedics, Sfantul Apostol Andrei Emergency County Hospital, Galati, Romania
| | - Elena Niculet
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of Anatomopathology, Sfantul Apostol Andrei Emergency County Hospital, Galati, Romania
| | - Alin Laurentiu Tatu
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of Dermatology and Venereal Diseases, Sfanta Cuvioasa Parascheva Clinical Hospital for Infectious Diseases, Galati, Romania
| | - Dorel Firescu
- Department of Medicine and Pharmacy, Dunarea de Jos University of Galati, Romania.,Department of General Surgery, Sfantul Apostol Andrei Emergency County Hospital, Galati, Romania
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Alotaibi AM, Alfawaz M, Felemban L, Moshref L, Moshref R. Complicated appendicitis increases the hospital length of stay. Surg Open Sci 2022; 9:64-68. [PMID: 35692621 PMCID: PMC9178463 DOI: 10.1016/j.sopen.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/27/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background There are insufficient data from Saudi Arabia regarding appendectomy outcomes and hospital length of stay. Further, there is a need to compare the length of stay of Saudi patients and the literature. The purpose is to evaluate the surgical outcomes and hospital length of stay for complicated appendicitis and simple appendicitis. Method This is a single-center retrospective review of patients who had undergone an appendectomy between 2016 and 2018. The patients were divided into 2 groups: complicated appendicitis versus simple appendicitis. Results Of 449 patients who underwent appendectomy, 60 (13.4%) had complicated appendicitis. The complicated appendicitis was significantly associated with increased age, pain duration, neutrophilia, high C-reactive protein, fecalith presence, and free fluid. The incidence rate of surgical site infection was 5.8% (identified in 26 patients). Compared to simple appendicitis, complicated appendicitis was associated more with wound infection (1.8% vs 10%, respectively, P = .001), postoperative collection (1.2% vs 11.6%, respectively, P = .001), and readmission within 30 days (2.3% vs 13.4%, respectively, P = .001). By multivariate analysis, factors associated more with increased hospitalization were pain duration (hazard ratio = 2.37, 95% confidence interval = 1.09–5.16, P = .029), operative time (hazard ratio = 2.09, 95% confidence interval = 1.04–4.21, P = .038), and complicated appendicitis (hazard ratio = 6.61, 95% confidence interval = 2.67–14.21, P = .001). Conclusion Complicated appendicitis correlates with significant morbidity, readmission rate, and 6 times more hospital LOS than simple appendicitis. This review might help in appreciating the burden of complicated appendicitis on hospital length of stay, which needs allocating patients and planning the discharge day for hospitals with limited beds. Practically one fifth of acute appendicitis will be complicated. Complicated appendicitis increases conversion to open, surgical site infection, hospital length of stay, and 30-day readmission rate. Prolonged operation time and complicated appendicitis are independent risk factors to increase hospitalization.
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Affiliation(s)
- Abdulrahman Muaod Alotaibi
- Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
- Department of Surgery, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
- Corresponding author at: Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia. Office contact number: 00966 0122334444, mobile contact no. + 966 504707351. @aotaib1
| | - Mohammed Alfawaz
- Department of Medicine, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Lina Felemban
- Department of Surgery, King Abdul-Aziz Medical City, National Guard Hospital, Jeddah, Saudi Arabia
| | - Leena Moshref
- Department of Surgery, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Rana Moshref
- Department of Surgery, Dr Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
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Aiyoshi T, Masumoto K, Tanaka N, Sasaki T, Chiba F, Ono K, Jimbo T, Urita Y, Shinkai T, Takayasu H, Hitomi S. Optimal First-Line Antibiotic Treatment for Pediatric Complicated Appendicitis Based on Peritoneal Fluid Culture. Pediatr Gastroenterol Hepatol Nutr 2021; 24:510-517. [PMID: 34796095 PMCID: PMC8593360 DOI: 10.5223/pghn.2021.24.6.510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/15/2021] [Accepted: 09/05/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Consensus is lacking regarding the optimal antibiotic treatment for pediatric complicated appendicitis. This study determined the optimal first-line antibiotic treatment for pediatric patients with complicated appendicitis based on peritoneal fluid cultures. METHODS This retrospective study examined the cases of pediatric patients who underwent appendectomy for complicated appendicitis at our institution between 2013 and 2019. Peritoneal fluid specimens obtained during appendectomy were cultured for the presence of bacteria. RESULTS Eighty-six pediatric patients were diagnosed with complicated appendicitis. Of them, bacteria were identified in 54 peritoneal fluid samples. The major identified bacteria were Escherichia coli (n=36 [66.7%]), Bacteroides fragilis (n=28 [51.9%]), α-Streptococcus (n=25 [46.3%]), Pseudomonas aeruginosa (n=10 [18.5%]), Enterococcus avium (n=9 [16.7%]), γ-Streptococcus (n=9 [16.7%]), and Klebsiella oxytoca (n=6 [11.1%]). An antibiotic susceptibility analysis showed E. coli was inhibited by sulbactam/ampicillin in 43.8% of cases versus cefmetazole in 100% of cases. Tazobactam/piperacillin and meropenem inhibited the growth of 96.9-100% of the major identified bacteria. E. coli (100% vs. 84.6%) and P. aeruginosa (100% vs. 80.0%) were more susceptible to amikacin than gentamicin. CONCLUSION Tazobactam/piperacillin or meropenem is a reasonable first-line antibiotic treatment for pediatric complicated appendicitis. In the case of aminoglycoside use, amikacin is recommended.
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Affiliation(s)
- Tsubasa Aiyoshi
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kouji Masumoto
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Nao Tanaka
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takato Sasaki
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Fumiko Chiba
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kentaro Ono
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takahiro Jimbo
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuhisa Urita
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Toko Shinkai
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hajime Takayasu
- Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shigemi Hitomi
- Department of Infectious Diseases, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Theodorou CM, Stokes SC, Hegazi MS, Brown EG, Saadai P. Is Pseudomonas infection associated with worse outcomes in pediatric perforated appendicitis? J Pediatr Surg 2021; 56:1826-1830. [PMID: 33223225 PMCID: PMC8096855 DOI: 10.1016/j.jpedsurg.2020.10.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/11/2020] [Accepted: 10/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is little information on the effects of Pseudomonas infection on outcomes in perforated appendicitis. As Pseudomonas is not covered by many empiric appendicitis antibiotic regiments, we hypothesized that children with Pseudomonas would have worse outcomes. METHODS Patients <18 years old undergoing appendectomy for perforated appendicitis at a tertiary children's hospital 2015-2019 were included and were stratified by presence of Pseudomonas on intraoperative culture. The primary outcome was post-operative organ-space infection (SSI). RESULTS Intraoperative cultures were collected in 58.4% of patients (n = 149/255) with 22.2% (n = 33) positive for Pseudomonas. SSIs occurred in 21.2% of children with Pseudomonas compared to 20.7% of children without Pseudomonas (p = 0.9). Children with Pseudomonas had longer antibiotic duration (9.1 vs. 6.7 days, p = 0.03) and LOS (6.7 vs. 5.9 days, p = 0.03) than those without, but a similar rate of post-operative interventions (12.2% vs. 19.0%, p = 0.4), hospital costs ($28,860 vs. $23,945, p = 0.3), ED visits (9.1% vs. 19.9%, p = 0.3), and readmissions (9.1% vs. 9.5%, p = 1). CONCLUSION Pseudomonas was identified in 22% children with perforated appendicitis and was associated with longer antibiotic durations and LOS, but similar rates of SSI, post-operative interventions, and readmissions compared to children without Pseudomonas. Empiric coverage of Pseudomonas may not be necessary.
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Affiliation(s)
- Christina M Theodorou
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA.
| | - Sarah C Stokes
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
| | - Mennatalla S Hegazi
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
| | - Erin G Brown
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
| | - Payam Saadai
- University of California Davis Medical Center, Department of Pediatric General, Thoracic, and Fetal Surgery, Sacramento, CA, USA
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Dabaja-Younis H, Farah H, Miron R, Geffen Y, Slijper N, Steinberg R, Kassis I. The intraperitoneal bacteriology and antimicrobial resistance in acute appendicitis among children: a retrospective cohort study between the years 2007-2017. Eur J Pediatr 2021; 180:2091-2098. [PMID: 33594543 DOI: 10.1007/s00431-021-03994-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/24/2022]
Abstract
This study aims to describe the microbiology and susceptibility profile of the intraperitoneal flora in complicated appendicitis. It is a retrospective cohort study including children < 18-year-old with pathologically confirmed appendicitis, from 2007 to 2017. It included 1466 children. Intraperitoneal samples were obtained from 655 (44.7%) patients, and 201 (30.7%) had positive culture with 395 pathogens. Gram-negative rods comprised 67.6%, Gram-positive cocci 21.5%, and anaerobes 10.9% of the isolates. Gram-positive cocci were detected in 67 (37.8%) patients. Milleri group Streptococci was the most frequently isolated Gram-positive (44.7%). The proportional rate of Milleri group Streptococci from Gram-positive cocci increased from 9.5 to 56.3% (P < 0.001, OR 12.214). Patients with Gram-positive cocci had longer hospital stay (mean 9.36 + 6.385 vs 7.72 + 4.582, P = 0.036, (CI -3.165, -0.105)) and more complicated disease (89.5% vs 78.4%, P = 0.045, OR 2.342). Patients with Milleri group Streptococci isolates readmitted more frequently (26.5% vs 13.2%, P = 0.05, OR 2.37). Resistance to amoxicillin-clavulanate, gentamicin, ceftazidime, piperacillin-tazobactam, and amikacin were detected in 29.1%, 6.5%, 2.3%, 1.2%, and 0.7% of the Gram-negative rods, respectively.Conclusion: The rates of Gram-positive cocci and particularly Milleri group Streptococci in peritoneal fluid are increasing. More complicated disease and longer hospital stay in Gram-positive cocci and higher readmission rate in Milleri group Streptococci. These emphasize the role of anti-Gram-positive antimicrobials. What is known: • Gram-negative rods are the main isolates in complicated appendicitis. • The choice of antibiotic regimen is an unsettled issue due to resistance. What is new: • Increased rate of Gram-positive cocci and Milleri group Streptococci. • More complicated disease, longer hospital stay, and higher readmission rate.
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Affiliation(s)
- Halima Dabaja-Younis
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel.
| | - Hanna Farah
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
| | - Ran Miron
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Healthcare Center, Haifa, Israel
| | - Nadav Slijper
- Pediatric Surgery Department, Rambam Healthcare Center, Haifa, Israel
| | - Ran Steinberg
- Pediatric Surgery Department, Rambam Healthcare Center, Haifa, Israel
| | - Imad Kassis
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
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9
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Peña ME, Sadava EE, Laxague F, Schlottmann F. Usefulness of intraoperative culture swabs in laparoscopic appendectomy for complicated appendicitis. Langenbecks Arch Surg 2020; 405:691-695. [PMID: 32592043 DOI: 10.1007/s00423-020-01913-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Intraabdominal abscess (IAA) is a feared complication after laparoscopic appendectomy (LA) for complicated appendicitis. Benefits of obtaining intraoperative culture swabs (ICS) still remain controversial. We aimed to determine whether ICS modify the rate and management of IAA after LA for complicated appendicitis. METHODS A consecutive series of patients who underwent LA for complicated appendicitis from 2008 to 2018 were included. The cohort was divided into two groups: group 1 (G1), with ICS, and group 2 (G2), without ICS. Demographics, operative variables, pathogen isolation, antibiotic sensitivity, and postoperative outcomes were analyzed. RESULTS A total of 1639 LA were performed in the study period. Of these, 270 (16.5%) were complicated appendicitis; 90 (33%) belonged to G1 and 180 (67%) to G2. In G1, a higher proportion of patients had generalized peritonitis (G1, 63.3%; G2, 35%; p < 0.01). Seventy-two (80%) patients had positive cultures in G1. The most frequently isolated bacteria were E. coli (66.7%), Bacteroides spp. (34.7%), and Streptococcus spp. (19.4%). In 26 (36%) patients, the initial empiric antibiotic course was modified due to bacterial resistance. The rate of IAA was higher in patients with ICS (G1, 21.1%; G2, 9.4%; p = 0.01). IAA was treated similarly in both groups. A different type of bacteria was isolated in 7 (53.8%) patients with new culture swabs. CONCLUSIONS Obtaining ICS in LA for complicated appendicitis with further antibiotic adjustment to the initial pathogen did not lower the incidence of postoperative IAA and did not modify the treatment needed for this complication.
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Affiliation(s)
- María E Peña
- Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredón 1640, C1118AAT, Buenos Aires, Argentina.
| | - Emmanuel E Sadava
- Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredón 1640, C1118AAT, Buenos Aires, Argentina
| | - Francisco Laxague
- Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredón 1640, C1118AAT, Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredón 1640, C1118AAT, Buenos Aires, Argentina
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Gouda SM, Abdelaal AM, Elgaml SA, Ezzeldein SA, Eisa EF, Hashish EA. Local peritonitis and omental bursitis as sequelae of abomasal ulceration in buffaloes ( Bubalus bubalis): clinical findings and outcome of treatment. Vet Q 2020; 40:51-57. [PMID: 31955661 PMCID: PMC7034438 DOI: 10.1080/01652176.2020.1718796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Abomasal ulcers are difficult to diagnose clinically with limited therapeutic approach to combat the disease. Omental bursitis (OB) and local peritonitis (LP) are known sequelae of abomasal ulcer in cows. In this study, differentiation between OB and LP in regard to clinical symptoms, biochemical analyses and the response to treatment in Buffaloes was done. Twenty buffaloes (Bubalus bubalis) were admitted with a history of intermittent appetite, wasting and mild abdominal distension during the period between March 2016 and August 2018. All cases were female (12 recently calved, 2 pregnant, 6 non-pregnant) aging from 3 to 9 years and weighing 350–600 kg. For comparison, 10 apparently healthy non-pregnant female buffaloes were used as controls. Abdominal ultrasonography confirmed the presence of 11 OB and 9 LP in admitted cases. Laboratory analysis revealed hyperproteinemia and hypoalbuminemia in OB. Hypokalemia and hypochloremia were detected in both OB and LP. Ultrasonography showed hypo-anechoic content with echoic stippling surrounded by echogenic wall in OB, whereas echogenic strands interspersed with anechoic fluid was reported in LP. Intra-lesional lavage by normal saline was applied several times under ultrasongraphic guidance followed by gentamicin 10% intramuscular and H2 antagonist intravenous for 5 days as well as parenteral and enteral fluid therapy. Seven cases of OB clinically improved, whereas no improvements were found in LP cases. OB secondary to abomasal ulcer has a good prognosis in contrast to LP. Ultrasonography provides a useful diagnostic tool and therapeutic guidance for such diseases.
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Affiliation(s)
- Shaimaa M Gouda
- Department of Animal Medicine, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed M Abdelaal
- Department of Animal Medicine, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Shimaa A Elgaml
- Department of Clinical Pathology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Shimaa A Ezzeldein
- Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Eslam F Eisa
- Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Emad A Hashish
- Department of Clinical Pathology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
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Beltrán Higuera SJ, Cruz Bulla M, Pedraza Salcedo EC, Mendivelso Duarte FO. Sensibilidad antimicrobiana en aislamientos de líquido peritoneal de niños intervenidos por abdomen agudo e infección intraabdominal. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La apendicitis aguda es causa frecuente de infección intraabdominal en pediatría. La elección del antibiótico se basa en los hallazgos quirúrgicos macroscópicos, el criterio médico, las guías locales o internacionales y, en pocas ocasiones, en el resultado de los aislamientos bacterianos en cultivos de líquido peritoneal y las tasas locales de resistencia. Se analizaron la frecuencia y la sensibilidad microbiológica de los cultivos de muestras de líquido peritoneal de pacientes de un mes a 16 años de edad con manejo quirúrgico por abdomen agudo con sospecha de infección intraabdominal. Materiales y métodos. Se llevó a cabo un estudio prospectivo de cohorte con análisis de las historias clínicas y de resultados de laboratorio de niños sometidos a cirugía por abdomen agudo, en la que el cirujano tomó muestra del líquido peritoneal para la tipificación y determinación de los perfiles de sensibilidad de los microorganismos aislados. Los datos se analizaron con el programa Stata™, versión15.0. Resultados. Se identificaron 303 casos, de los cuales el 93,6 % recibió profilaxis antibiótica con ampicilina-sulbactam y clindamicina-amikacina. El 95,3 % de los procedimientos fueron apendicectomías. Se tomó cultivo del 50 % de las apendicitis perforadas. Se aislaron 48 microorganismos; el más frecuente (2,7 %) fue Escherichia coli positiva para BLEE. El 100 % de los microorganismos resultaron ser sensibles a la amikacina, el 97,2 % al meropenem, y el 94,4 %, a la ciprofloxacina, el cefepime y el ceftazidime. La resistencia más frecuente (37,1 %) fue contra la combinación de ampicilina y sulbactam, en los gérmenes Gram negativos. Discusión. La evaluación de la sensibilidad antimicrobiana de los aislamientos de líquido peritoneal de los procedimientos quirúrgicos en pediatría, es una buena práctica clínica que orienta al cirujano en la adecuada selección del esquema antibiótico y, además, disminuye el riesgo de falla terapéutica temprana y la posibilidad de mayor resistencia o complicaciones infecciosas.
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12
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Recovery of aerobic and anaerobic bacteria from patients with acute appendicitis using blood culture bottles. ACTA ACUST UNITED AC 2019; 39:699-706. [PMID: 31860181 PMCID: PMC7363352 DOI: 10.7705/biomedica.4774] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 12/29/2022]
Abstract
Introducción. La apendicitis aguda es la primera causa de abdomen agudo; sin embargo, poco se conoce sobre las bacterias asociadas y su perfil de sensibilidad. Objetivo. Identificar y determinar el patrón de resistencia de las bacterias aerobias y anaerobias aisladas en cultivo de líquido periapendicular tomado de los pacientes con apendicitis aguda, y establecer la proporción de bacterias según la fase clínica. Materiales y métodos. Se llevó a cabo un estudio descriptivo y prospectivo en el Hospital Universitario de San José de Bogotá (Colombia), en pacientes mayores de 16 años sometidos a apendicectomía abierta. Se tomaron muestras de líquido periapendicular, las cuales se sembraron directamente en botellas de hemocultivos para aerobios y anaerobios. Resultados. Se incluyeron 154 pacientes. Del total de cultivos, el 87 % (n=134) fueron positivos: 77 % (n=118) para aerobios y 51 % (n=79) para anaerobios. La proporción de cultivos positivos fue inferior en los casos de apendicitis no complicada, en comparación con aquellos de apendicitis complicada (80 % (66/83) Vs. 95 % (67/71); p=0,003). Los microorganismos aislados con mayor frecuencia fueron: Escherichia coli (53 %) (n=84), Bacteroides sp. (25 %) (n=25), Propionibacterium acnes (21 %) (n=21), Staphylococci coagulasa negativo (17 %) (n=27), Enterococcus sp. (10 %) (n=15) y Fusobacterium sp. (11 %) (n=11). La sensibilidad de E. coli a la amplicilina sulbactam fue de 30 %. La sensibilidad de Bacteroides spp. a la clindamicina y la ampicilina sulbactam fue de 91 %. El 100 % de los anaerobios fueron sensibles a piperacilina tazobactam, ertapenem, meropenem y metronidazol. Conclusiones. Los cultivos intraoperatorios son pertinentes en la apendicitis para determinar el patrón epidemiológico local, y establecer los antibióticos profilácticos y terapéuticos para esta enfermedad. Su siembra directa en botellas de hemocultivo permite una gran recuperación de microorganismos.
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Hamdy RF, Handy LK, Spyridakis E, Dona D, Bryan M, Collins JL, Gerber JS. Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated Appendicitis in Children. Surg Infect (Larchmt) 2019; 20:399-405. [PMID: 30874482 DOI: 10.1089/sur.2018.234] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. The antibiotic choice differs widely across children's hospitals, and the optimal regimen for perforated appendicitis remains unclear. Methods: We conducted a retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large tertiary-care children's hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes with confirmation by chart review. Patients were excluded if they had been admitted ≥48 hours prior to diagnosis, had a history of appendicitis, received inotropic agents, were immunocompromised, or were given an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an anti-pseudomonal drug (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days after diagnosis. The primary outcome of interest was post-operative complications, defined as development of an incisional infection or abscess within six weeks of hospital discharge. Results: Of the 353 children who met the inclusion criteria, 252 (71%) received CTX/MTZ and the others received an anti-pseudomonal regimen. A post-operative complication occurred in 37 (14.7%) of the CTX/MTZ group versus 18 (17.8%) of the anti-pseudomonal group. Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on anti-pseudomonal antibiotics (p = 0.32). In a multivariable logistic regression model adjusting for sex, age, ethnicity, and duration of symptoms prior to presentation, the adjusted odds ratio for post-operative complications in children receiving anti-pseudomonal antibiotics was 1.25 (95% confidence interval 0.66-2.40). Conclusion: Post-operative complication rates did not differ for children treated with CTX/MTZ versus a broader-spectrum regimen.
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Affiliation(s)
- Rana F Hamdy
- 1 Department of Pediatrics, Children's National Health System, Washington, DC
| | - Lori K Handy
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evangelos Spyridakis
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniele Dona
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Bryan
- 3 Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia
| | - Joy L Collins
- 4 Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- 2 Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Akingboye AA, Davies B, Tien T. Pus Samples in Complicated Appendicitis: An Important Investigation or a Waste of Resources: A Prospective Cohort Study. Scand J Surg 2019; 108:55-60. [PMID: 29973114 DOI: 10.1177/1457496918783721] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND AIMS: Appendicitis is a common presentation to hospital with appendectomy being the treatment of choice. Pre-operative administration of broad-spectrum antibiotics is common, but obtaining intra-abdominal pus samples is not. After an initial 6-month retrospective audit and departmental teaching on the importance of intra-peritoneal pus sampling, we aimed to determine whether intra-operative pus samples changed antibiotic management. MATERIALS AND METHODS: Following the initial audit cycle, a 6-month prospective cohort study was conducted. Clinical data were collected on a predetermined proforma to assess the effectiveness of the intervention and antibiotic prescribing practice. The data collected during the whole 1-year period was analyzed. RESULTS: During the 1-year period, 440 patients were identified as undergoing a laparoscopic procedure. After exclusion, 261 patients were identified as undergoing laparoscopic appendectomies, of which 141 (54%) were classified as complicated laparoscopic appendectomies. A total of 35 out of 141 (25%) pus samples were sent of which 24 (17%) resulted in positive cultures, with only nine of these positive cultures reported prior to the patient being discharged. No patient had their antibiotic regimen changed as a result of the culture results. There were three cases of cultures resistant to local antibiotics, but without significant clinical outcome. One of these patients developed a post-operative complication, but the antibiotic regimen was changed to broad spectrum rather than a specific antibiotic based on culture sensitivity. Of the 141 patients with complicated laparoscopic appendectomies, five (3.5%) developed post-operative complications: one readmission requiring a laparoscopic washout for pelvic collection, three (2%) cases of pelvic collections managed conservatively, and one case of prolonged paralytic ileus managed non-operatively. CONCLUSION: Overall, none of the patients with positive cultures had a change in prescribed antibiotics based on culture results. Hence, the routine practice of intra-peritoneal pus sampling following complicated appendicitis remains of little clinical value.
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Affiliation(s)
- A A Akingboye
- 1 Department of General Surgery, Peterborough City Hospital, Peterborough, UK
| | - B Davies
- 1 Department of General Surgery, Peterborough City Hospital, Peterborough, UK
| | - T Tien
- 2 Department of General Surgery, Colchester Hospital University NHS Foundation Trust, Colchester, UK
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