1
|
Alabbad J, Alhamly H, Alrubaiaan A, Kabli A, Abdulraheem F. The utility of intraperitoneal drain placement after laparoscopic appendectomy for perforated appendicitis in postoperative intraperitoneal abscess prevention. Surg Endosc 2024; 38:3571-3577. [PMID: 38750172 DOI: 10.1007/s00464-024-10869-w] [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: 02/01/2024] [Accepted: 04/17/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Perforated appendicitis is associated with postoperative development of intraperitoneal abscess. Intraperitoneal drain placement during appendectomy is thought to reduce the risk of developing postoperative intraperitoneal abscess. The aim of this study was to determine whether intraperitoneal drainage could reduce the incidence of intraperitoneal abscess formation after laparoscopic appendectomy for perforated appendicitis. METHODS This is a retrospective study of all patients (aged 7 and above) who were diagnosed with perforated appendicitis and subsequently underwent laparoscopic appendectomy between January 2018 and December 2022 at two government hospitals in the state of Kuwait. Demographic, clinical, and perioperative characteristics were compared between patients who underwent intraoperative intraperitoneal drain placement and those who did not. The primary outcome was the development of postoperative intraperitoneal abscess. Secondary outcomes included overall postoperative complications, superficial surgical site infection (SSI), length of stay (LOS), readmission and postoperative percutaneous drainage. RESULTS A total of 511 patients met the inclusion criteria between 2018 and 2022. Of these, 307 (60.1%) underwent intraoperative intraperitoneal drain placement. Patients with and without drains were similar regarding age, sex, and Charlson Comorbidity Index (CCI) (Table 1). The overall rate of postoperative intraperitoneal abscess was 6.1%. Postoperatively, there was no difference in postoperative intraperitoneal abscess formation between patients who underwent intraperitoneal drain placement and those who did not (6.5% vs. 5.4%, p = 0.707). Patients with intraperitoneal drains had a longer LOS (4 [4, 6] vs. 3 [2, 5] days, p < 0.001). There was no difference in the overall complication (18.6% vs. 12.3%, p = 0.065), superficial SSI (2.9% vs. 2.5%, p = 0.791) or readmission rate (4.9% vs. 4.4%, p = 0.835). CONCLUSIONS Following laparoscopic appendectomy for perforated appendicitis, intraperitoneal drain placement appears to confer no additional benefit and may prolong hospital stay.
Collapse
Affiliation(s)
- Jasim Alabbad
- Mubarak Al-Kabeer Hospital, Jabriya, Kuwait.
- Department of Surgery, College of Medicine, Kuwait University, P.O. Box 24923, 3110, Safat, Kuwait.
| | | | | | | | | |
Collapse
|
2
|
Keane OA, Motley T, Robinson J, Smith A, Short HL, Santore MT. Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative. J Pediatr Surg 2024; 59:1058-1065. [PMID: 38030531 DOI: 10.1016/j.jpedsurg.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative. METHODS On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation. RESULTS In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001). CONCLUSION Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care. STUDY TYPE Quality improvement. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Theresa Motley
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jenny Robinson
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alexis Smith
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| |
Collapse
|
3
|
Snyder KB, Hunter CJ, Buonpane CL. Perforated Appendicitis in Children: Management, Microbiology, and Antibiotic Stewardship. Paediatr Drugs 2024; 26:277-286. [PMID: 38653916 DOI: 10.1007/s40272-024-00630-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
Abstract
Although appendicitis has been described for more than 300 years, its optimal management remains a topic of active investigation. Acute appendicitis is the most common cause of peritonitis in children, and rates of perforated appendicitis are much higher in children than in adults. Increased risk for perforated appendicitis in children is related to a delay in diagnosis due to age, size, access to care, and more. Surgical options include immediate appendectomy versus nonoperative management with intravenous antibiotics ± a drainage procedure, with a subsequent interval appendectomy. Microbiota of perforated appendicitis in children most often includes Escherichia coli, Bacteroides fragilis, Streptococcus, and more. Even though the most common organisms are known, there is a large variety of practice when it comes to postoperative antibiotic management in these patients. Studies discuss the benefits of mono- versus dual or triple therapy without a particular consensus regarding what to use. This is reflected across differing practices at various institutions. In this review, we aim to explore the implications of perforated appendicitis in pediatrics, common organisms seen, antibiotic regimen coverage, and the implications of variations of practice. Resistance to commonly used broad-spectrum antibiotics is evolving, therefore minimization of care variability is needed for improved patient outcomes and proper antibiotic stewardship.
Collapse
|
4
|
Cironi K, Albuck AL, McLafferty B, Mortemore AK, McCarthy C, Hussein M, Issa PP, Metz T, Herrera M, Toraih E, Taghavi S, Kandil E, Turner J. Risk Factors for Postoperative Infections Following Appendectomy of Complicated Appendicitis: A Meta-analysis and Retrospective Single-institutional Study. Surg Laparosc Endosc Percutan Tech 2024; 34:20-28. [PMID: 37852230 DOI: 10.1097/sle.0000000000001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/22/2023] [Indexed: 10/20/2023]
Abstract
Patients with complicated appendicitis have an increased risk for postoperative infections. Potential risk factors for postoperative infections through a meta-analysis and retrospective chart review are discussed. A meta-analysis consisting of 35 studies analyzing complicated appendicitis treated with an appendectomy noting at least 1 postoperative infection was performed. A retrospective review was then conducted in patients diagnosed with complicated appendicitis after appendectomy. Of 5326 patients in total, 15.4% developed postoperative infections. Laparoscopic surgery and perioperative hyperoxygenation were found to be protective factors for the development of infection. Retrospectively, 53.2% of patients presented with complicated appendicitis. Patients with complicated appendicitis were more likely to be older in age and have an increased length of stay. Patient demographics, operative time, and comorbid status had no effect on postoperative infection or readmission rate. Physicians should strongly consider minimally invasive techniques to treat all cases of complicated appendicitis irrespective of comorbidities, age, sex, or body mass index.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Peter P Issa
- Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA
| | | | | | - Eman Toraih
- Department of Surgery, Division of Endocrine and Oncologic Surgery
- Department of Genetics, Histology and Cell Biology, Suez Canal University Faculty of Medicine, Ismailia, Egypt
| | - Sharven Taghavi
- Department of Surgery, Division of Trauma and Critical Care, Tulane University School of Medicine
| | - Emad Kandil
- Department of Surgery, Division of Endocrine and Oncologic Surgery
| | - Jacquelyn Turner
- Department of Surgery, Division of Endocrine and Oncologic Surgery
| |
Collapse
|
5
|
Fansiwala K, Rusher A, Shore B, Herfarth HH, Barnes E, Kochar B, Chang S. Oral vs Intravenous Discharge Antibiotic Regimens in the Management of Intra-abdominal Abscesses in Penetrating Crohn's Disease. Inflamm Bowel Dis 2023:izad299. [PMID: 38150318 DOI: 10.1093/ibd/izad299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Antibiotics are a cornerstone in management of intra-abdominal abscesses in Crohn's disease (CD). Yet, the optimal route of antibiotic administration is poorly studied. We aimed to compare surgical and nonsurgical readmission outcomes for patients hospitalized for intra-abdominal abscesses from CD discharged on oral (PO) or intravenous (IV) antibiotics. METHODS Data for patients with CD hospitalized for an intra-abdominal abscess were obtained from 3 institutions from January 2010 to December 2020. Baseline patient characteristics were obtained. Primary outcomes of interest included need for surgery and hospital readmission within 1 year from hospital discharge. We used multivariable logistic regression models and Cox regression analysis to adjust for abscess size, history of prior surgery, history of penetrating disease, and age. RESULTS We identified 99 patients discharged on antibiotics (PO = 74, IV = 25). Readmissions related to CD at 12 months were less likely in the IV group (40% vs 77% PO, P = .01), with the IV group demonstrating a decreased risk for nonsurgical readmissions over time (hazard ratio, 0.376; 95% confidence interval, 0.176-0.802). Requirement for surgery was similar between the groups. There were no differences in time to surgery between groups. CONCLUSIONS In this retrospective, multicenter cohort of CD patients with intra-abdominal abscess, surgical outcomes were similar between patients receiving PO vs IV antibiotics at discharge. Patients treated with IV antibiotics demonstrated a decreased risk for nonsurgical readmission. Further prospective trials are needed to better delineate optimal route of antibiotic administration in patients with penetrating CD.
Collapse
Affiliation(s)
- Kush Fansiwala
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alison Rusher
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Shore
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Shannon Chang
- Inflammatory Bowel Disease Center, Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
6
|
Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
Collapse
Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
| |
Collapse
|
7
|
Stewart S, Cruz-Centeno N, Marlor DR, St Peter SD, Oyetunji TA. Bridging the Gap: Pediatric General Surgery for the Pediatrician. Pediatr Rev 2023; 44:632-643. [PMID: 37907417 DOI: 10.1542/pir.2022-005894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
|
8
|
Detollenaere J, Van Ingelghem I, Van den Heede K, Vlayen J. Systematic literature review on the effectiveness and safety of paediatric hospital-at-home care as a substitute for hospital care. Eur J Pediatr 2023:10.1007/s00431-023-04916-2. [PMID: 37010537 DOI: 10.1007/s00431-023-04916-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 04/04/2023]
Abstract
The hospital landscape is shifting to new care models to meet current challenges in demand, technology, available budgets and staffing. These challenges also apply to the paediatric population, leading to a reduction in paediatric hospital beds and occupancy rates. Paediatric hospital-at-home (HAH) care is used to substitute hospital care in an attempt to bring hospital services closer to children's homes. In addition, these models attempt to avoid fragmentation of care between hospitals and the community. An important prerequisite for this paediatric HAH care is that it is safe and at least as effective as standard hospital care. The aim of this systematic review is to analyse the evidence on the impact of paediatric HAH care on hospital utilisation, patient outcomes and costs. Four bibliographic databases (Medline, Embase, Cinahl and Cochrane Library) were systematically searched for RCTs and pseudo-RCTs that studied the effectiveness and safety of short-term paediatric HAH care with a focus on models as an alternative to acute hospital admissions. Pseudo-RCTs are defined as observational studies that mimic the design of an RCT, but without randomisation. Outcomes of interest were the length of stay, acute (re)admissions, adverse health outcomes, therapy adherence, parental satisfaction or experience and costs. Only articles written in English, Dutch and French conducted in upper-middle and high-income countries and published between 2000 and 2021 were included. Quality assessment was carried out by two assessors using the Cochrane Collaboration's tool for assessing the risk of bias. Reporting is done in accordance with the PRISMA guidelines. We identified 18 (pseudo) RCTs and 25 publications of low to very low quality. Most of the included RCTs focused on the neonatal population: phototherapy for neonatal jaundice, early discharge after birth combined with outpatient neonatal care. Other RCTs focused on chemotherapy for acute lymphoblastic leukaemia, diabetes type 1 education, oxygen therapy for acute bronchiolitis, an outpatient service for children with infectious diseases and antibiotic treatment for low-risk febrile neutropenia, cellulitis and perforated appendicitis. The identified study results show that paediatric HAH care is not associated with more adverse events or hospital readmissions. The impact of paediatric HAH care on costs is less clear. Conclusions: This review suggests that paediatric HAH care is not associated with more adverse events or hospital readmissions for various clinical indications compared to a standard hospital. Because of the low to very low level of evidence, it is worthwhile to further investigate safety, efficacy and cost effects under strict and well-controlled conditions. This systematic review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention. What is Known: • The hospital landscape is shifting new models of care to meet current challenges in demand, technology, staffing and models of care. Paediatric HAH care is one of these models. Previous literature reviews are inconclusive whether this is a safe and effective way of providing care. What is New: • New evidence suggests that paediatric HAH care for various clinical indications is not associated with adverse events or hospital readmissions compared to a standard hospital. Current evidence is characterised by a low level of quality. • The current review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention.
Collapse
Affiliation(s)
- Jens Detollenaere
- Belgian Health Care Knowledge Centre (KCE), Boulevard du Jardin Botanique 55, Brussels, Belgium.
| | - Ingrid Van Ingelghem
- AZ Klina, Augustijnslei 100, Brasschaat, Belgium
- UZ Antwerpen, Drie Eikenstraat 655, Edegem, Belgium
| | - Koen Van den Heede
- Belgian Health Care Knowledge Centre (KCE), Boulevard du Jardin Botanique 55, Brussels, Belgium
- Leuven Institute for Healthcare Policy (KU Leuven), Kapucijnenvoer 35, Louvain, Belgium
| | - Joan Vlayen
- Sint-Trudo Hospital, Diestersteenweg 100, Sint Truiden, Belgium
| |
Collapse
|
9
|
Skertich NJ, Sullivan GA, Wiegmann AL, Becerra AZ, Madonna MB, Pillai S, Shah AN, Gulack BC. A shortened course of Amoxicillin/Clavulanate is the preferred antibiotic treatment after surgery for perforated appendicitis in children. J Pediatr Surg 2023; 58:558-563. [PMID: 35490055 DOI: 10.1016/j.jpedsurg.2022.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 03/22/2022] [Accepted: 03/29/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE Despite evidence supporting short course outpatient antibiotic treatment following appendectomy for perforated appendicitis, evidence of real-world implementation and consensus for antibiotic choice is lacking. We therefore aimed to compare outpatient antibiotic treatment regimens in a national cohort. METHODS We identified children who underwent surgery for perforated appendicitis between 2010 and 2018 using the PearlDiver database and compared 45-day disease-specific readmission between children who received shortened (5-8 days) versus prolonged (10-14 day) total antibiotic courses (inpatient intravenous and/or oral) completed with outpatient Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, and compared antibiotic type (5-14 days) to each other. RESULTS 4916 children were identified, 2001 (90.0%) treated with Amoxicillin/Clavulanate (5-14 days), 381 (19.0%) with shortened (5-8 days), 1464 (73.2%) with prolonged (10-14 days) courses. 222 (10.0%) were treated with Ciprofloxacin/Metronidazole, 44 (19.8%) with shortened, 174 (78.4%) with prolonged courses. Freedom from readmission was not different between prolonged and shortened course whether they received Amoxicillin/Clavulanate (adjusted hazard ratio [AHR] 1.54, 95%CI 0.95-2.5) or Ciprofloxacin/Metronidazole (AHR 3.49, 95%CI 0.45-27.3). Antibiotic type did not affect readmission rate (Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, AHR 1.21, 95%CI 0.71-2.05). CONCLUSION Prolonged antibiotic regimens are routinely prescribed despite evidence suggesting shorter courses and antibiotic choice are not associated with greater treatment failure. As it is better tolerated, we recommend a shortened course of Amoxicillin/Clavulanate for oral management of perforated appendicitis. STUDY DESIGN Retrospective. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Nicholas J Skertich
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States.
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Aaron L Wiegmann
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL 60612, United States
| | - Mary Beth Madonna
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Srikumar Pillai
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, 1653 West Congress Parkway, Kellogg 7, Chicago, IL 60612, United States
| |
Collapse
|
10
|
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.
Collapse
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.
| | | |
Collapse
|
11
|
Morita K, Fujiogi M, Michihata N, Matsui H, Fushimi K, Yasunaga H, Fujishiro J. Oral Antibiotics and Organ Space Infection after Appendectomy and Intravenous Antibiotics Therapy for Complicated Appendicitis in Children. Eur J Pediatr Surg 2023; 33:74-80. [PMID: 36220134 DOI: 10.1055/a-1958-7915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND There is little consensus regarding management after appendectomy for complicated appendicitis in children. Recent literature suggests that patients may be safely discharged without oral antibiotics after adequate intravenous antibiotics therapy. We conducted a nationwide retrospective cohort study comparing the proportion of postoperative organ space infection between patients discharged with and without oral antibiotics after appendectomy followed by intravenous antibiotics therapy for complicated appendicitis. METHODS Using the Diagnosis Procedure Combination database, we identified patients between 3 and 18 years of age who had undergone appendectomy for complicated appendicitis between July 2010 and March 2018. Propensity score-matched analyses were performed to compare outcomes between the groups with and without oral antibiotics. The primary outcome was readmission due to organ space infection within 60 days of discharge and the secondary outcome was 60-day readmission due to any reason. Additionally, we conducted a stabilized inversed probability of treatment weighting analysis as a sensitivity analysis. RESULTS We identified 13,100 eligible patients who had received oral antibiotics (n = 3,501) and who had not received oral antibiotics (n = 9,599). Propensity score matching created 2,769 pairs. Readmissions due to organ space infection were 3.4% and 5.2% in the nonusers and users of oral antibiotics, respectively (p = 0.007). The oral antibiotics users also had a significantly higher proportion of readmission due to any reason than the nonusers (5.5 vs. 7.4%, p = 0.004). The sensitivity analyses demonstrated consistent results. CONCLUSION Among children who had undergone appendectomy for complicated appendicitis, oral antibiotics following discharge after adequate intravenous antibiotics therapy may increase organ space infection.
Collapse
Affiliation(s)
- Kaori Morita
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
| | - Michimasa Fujiogi
- Department of Pediatric Surgery, National Center for Child Health and Development, Setagayaku, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
12
|
Hu A, Li J, Vacek J, Bouchard M, Ingram MC, McMahon M, Mithal LB, Raval MV, Reynolds M, Goldstein S. Antibiotic resistance is common in the cultures of intraabdominal abscess drainage after appendectomy. J Pediatr Surg 2022; 57:102-106. [PMID: 34991867 DOI: 10.1016/j.jpedsurg.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/14/2021] [Accepted: 12/04/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Intraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis. METHODS We performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected. RESULTS In total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage. CONCLUSIONS IAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Jennifer Li
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jonathan Vacek
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan Bouchard
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Martha-Conley Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Maxwell McMahon
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Leena B Mithal
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Seth Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| |
Collapse
|
13
|
Theodorou CM, Lee SY, Lawrence Y, Saadai P, Hirose S, Brown EG. The Utility of Discharge Antibiotics in Pediatric Perforated Appendicitis Without Leukocytosis. J Surg Res 2022; 275:48-55. [PMID: 35219251 PMCID: PMC10032146 DOI: 10.1016/j.jss.2022.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/14/2021] [Accepted: 01/26/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Optimal management of pediatric perforated appendicitis remains a topic of active investigation. Our institutional clinical practice guidelines (CPGs) were modified to discontinue antibiotics on discharge for patients with normal white blood cell count (WBC) without left shift. We hypothesized that patients would receive fewer antibiotics without increased complications. METHODS Patients <18 y old with perforated appendicitis who underwent laparoscopic appendectomy between November 1, 2016 and May 31, 2021 at a tertiary care children's hospital were included. Primary outcome was adverse events: postdischarge surgical site infection (SSI), 30-day emergency department (ED) visits, or readmissions. Outcomes were compared before and after CPG modification. Multivariable regression was performed to identify factors associated with SSI. RESULTS There were 113 patients pre- and 97 patients post-CPG modification. 23.1% of patients in the pre-cohort had an elevated discharge WBC or left shift compared to 18.9% of patients in the post-cohort (P = 0.48). Significantly fewer patients were prescribed antibiotics on discharge in the post-cohort (70.8% pre versus 14.4% post, P < 0.0001) and for fewer days (2 pre versus 0 post, P < 0.0001). Total antibiotic days decreased significantly (6.1 pre versus 4.6 post, P < 0.0001). There was an increase in postdischarge SSIs on univariate analysis (1.8% pre versus 9.3% post, P = 0.03), ED visits (9.7% pre versus 19.6% post, P = 0.04), and readmissions (5.3% pre versus 11.3% post, P = 0.13). On multivariable analysis, being in the post-cohort was not significantly associated with post-discharge SSIs after adjusting for sex, symptom duration, initial WBC, and discharge antibiotic duration (OR 0.25, 95% CI 0.04-1.4, P = 0.11). CONCLUSIONS Modification of a pediatric perforated appendicitis clinical practice guideline to discontinue antibiotics on discharge with a normal WBC without left shift was effective in decreasing antibiotic duration. This was associated with an increase in SSIs on univariate analysis, which did not persist on multivariable analysis and requires further investigation.
Collapse
Affiliation(s)
- Christina M Theodorou
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California.
| | - Su Yeon Lee
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Yemi Lawrence
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Payam Saadai
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Shinjiro Hirose
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| | - Erin G Brown
- Department of Pediatric General, Thoracic, and Fetal Surgery, University of California Davis Medical Center, Sacramento, California
| |
Collapse
|
14
|
Ferguson DM, Arshad SA, Avritscher EB, Li LT, Austin MT, Kawaguchi AL, Lally KP, Tsao K. Costs associated with postoperative intra-abdominal abscess in pediatric perforated appendicitis: A retrospective cohort study. Surgery 2022; 172:212-218. [PMID: 35279294 DOI: 10.1016/j.surg.2022.01.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/18/2021] [Accepted: 01/28/2022] [Indexed: 12/29/2022]
|
15
|
Spellberg B, Shorr AF. Opinion-Based Recommendations: Beware the Tyranny of Experts. Open Forum Infect Dis 2021; 8:ofab490. [PMID: 34805432 PMCID: PMC8599712 DOI: 10.1093/ofid/ofab490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/05/2021] [Indexed: 12/29/2022] Open
Affiliation(s)
- Brad Spellberg
- Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Andrew F Shorr
- Division of Pulmonary Critical Care Medicine, MedStar, Washington, District of Columbia, USA
| |
Collapse
|
16
|
Plattner AS, Newland JG, Wallendorf MJ, Shakhsheer BA. Management and Microbiology of Perforated Appendicitis in Pediatric Patients: A 5-Year Retrospective Study. Infect Dis Ther 2021; 10:2247-2257. [PMID: 34287780 PMCID: PMC8572942 DOI: 10.1007/s40121-021-00502-x] [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: 06/01/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION This study aims to assess the current epidemiology and microbiology of perforated appendicitis, how antibiotic choice and duration correlate with meaningful clinical outcomes, and whether serial white blood cell (WBC) counts provide clinical value. METHODS Five-year retrospective cohort study, 2015-2019, among 333 consecutive children, ages 0-18 years, treated at St. Louis Children's Hospital for perforated appendicitis. Main outcomes included length of stay (LOS), postoperative abscess formation, and readmission. Statistical analysis was performed with uni- and multi-variate analyses. RESULTS Intra-abdominal cultures most commonly grew Bacteroides fragilis (52%) and Escherichia coli (50%). Patients who initially received broad-spectrum antibiotics (meropenem, piperacillin-tazobactam, fourth-generation cephalosporins) for perforated appendicitis had greater rates of postoperative abscess formation (25% vs. 12%, p < 0.01) and LOS (7.0 vs. 5.7 days, p < 0.01). Similarly, antibiotics at time of discharge were associated with greater postoperative abscess formation (22% vs. 9%, p < 0.01) and LOS (6.4 vs. 5.6 days, p = 0.02). However, discharge with strictly oral antibiotics was not correlated with greater LOS, postoperative abscess formation, or readmission rates compared to discharge without antibiotics. Serial WBC counts had no predictive value for LOS, postoperative abscess formation, or readmission. CONCLUSIONS Bacteroides fragilis and E. coli were the most common intra-abdominal microbes for perforated appendicitis among our cohort. In non-critically ill children, the routine use of broad-spectrum antibiotics or continuation of antibiotics beyond discharge was not correlated with improved clinical outcomes. Additionally, WBC counts were not correlated with meaningful clinical outcomes.
Collapse
Affiliation(s)
- Alex S Plattner
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Michael J Wallendorf
- Division of Biostatistics, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Baddr A Shakhsheer
- Division of Pediatric Surgery, Department of Surgery, Washington University in St Louis School of Medicine, 1 Children's Place, Suite 6110-CB 8235, St Louis, MO, 63110, USA.
| |
Collapse
|
17
|
Orelaru F, Karabon P, Novotny N, Akay B, Brahmamdam P. Impact of Clostridium difficile infection on pediatric appendicitis. Pediatr Surg Int 2021; 37:865-870. [PMID: 33830299 DOI: 10.1007/s00383-021-04893-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Clostridium difficile is an important cause of nosocomial infection in the pediatric population. The purpose of this study is to estimate the impact of Clostridium difficile infection complicating pediatric acute appendicitis. METHODS This study utilizes the combined 2009 and 2012 Kids' Inpatient Database. Statistical analysis is weighted and was done using Survey Sampling and Analysis procedures in SAS 9.4. RESULTS We identified 176,934 cases with appendicitis and 0.2% (n = 358) had a concurrent diagnosis of C. difficile. The proportion of cases with C. difficile in perforated appendicitis was greater than in the non-perforated cases (0.39% vs. 0.06%; p < .01). Multivariate analysis showed that perforated appendicitis (OR 5.22), and anemia (OR 4.95) were independent predictors of C. difficile infection (p < .001). Adjusted for perforated appendicitis, cases with C. difficile had 4.78 days longer length of stay (LOS) and higher total charges of $29,887 (all p < 0.0001) compared to non-C. difficile cases. CONCLUSION C. difficile infection is a rare, but impactful complication of pediatric appendicitis and is associated with greater disease severity. Proper antibiotic stewardship could minimize the risk of C. difficile in pediatric appendicitis.
Collapse
Affiliation(s)
| | - Patrick Karabon
- Oakland University William Beaumont School of Medicine, Rochester, MI, US
| | - Nathan Novotny
- Oakland University William Beaumont School of Medicine, Rochester, MI, US.,Beaumont Health System, Royal Oak, MI, US
| | - Begum Akay
- Oakland University William Beaumont School of Medicine, Rochester, MI, US.,Beaumont Health System, Royal Oak, MI, US
| | - Pavan Brahmamdam
- Oakland University William Beaumont School of Medicine, Rochester, MI, US. .,Beaumont Health System, Royal Oak, MI, US.
| |
Collapse
|
18
|
IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy. Ann Surg 2021; 274:406-410. [PMID: 34132703 DOI: 10.1097/sla.0000000000005006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. METHODS A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. RESULTS One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. CONCLUSIONS In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.
Collapse
|
19
|
Ferguson DM, Anderson KT, Arshad SA, Garcia EI, Hebballi NB, Li LT, Kawaguchi AL, Lally KP, Tsao K. Prophylactic intraabdominal drains do not confer benefit in pediatric perforated appendicitis: Results from a quality improvement initiative. J Pediatr Surg 2021; 56:727-732. [PMID: 32709531 DOI: 10.1016/j.jpedsurg.2020.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/29/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis. METHODS A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed. RESULTS Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment. CONCLUSIONS A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - K Tinsley Anderson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Elisa I Garcia
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Nutan B Hebballi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Linda T Li
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Center for Surgical Trials and Evidence-based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, United States; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, United States.
| |
Collapse
|
20
|
Gordon AJ, Choi JH, Ginsburg H, Kuenzler K, Fisher J, Tomita S. Oral Antibiotics and Abscess Formation After Appendectomy for Perforated Appendicitis in Children. J Surg Res 2020; 256:56-60. [PMID: 32683057 DOI: 10.1016/j.jss.2020.05.082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022]
|
21
|
A Standardized Protocol for the Management of Appendicitis in Children Reduces Resource Utilization. Pediatr Qual Saf 2020; 5:e357. [PMID: 33134759 PMCID: PMC7591119 DOI: 10.1097/pq9.0000000000000357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022] Open
Abstract
Appendicitis is the most common condition requiring emergency surgery in children. We implemented a standardized protocol (SP) for treating children with appendicitis to provide more uniform care and reduce resource utilization.
Collapse
|
22
|
Rossidis AC, Brown EG, Payton KJ, Mattei P. Implementation of an evidence-based protocol after appendectomy reduces unnecessary antibiotics. J Pediatr Surg 2020; 55:2379-2386. [PMID: 32753275 DOI: 10.1016/j.jpedsurg.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Children with acute appendicitis have historically received intravenous antibiotics before and after appendectomy, yet recent literature supports minimizing postoperative antibiotics. In this study, we examined the impact of a standardized protocol that eliminates postoperative antibiotics for nonperforated appendicitis and discontinues antibiotics at discharge for perforated appendicitis. METHODS A retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis between May 2013 and March 2017 was performed. Preprotocol patients (5/1/2013-3/31/2015) were compared to postprotocol patients (5/1/2015-3/31/2017), excluding those who underwent surgery during the month of protocol introduction (4/2015). Primary outcomes were postoperative antibiotic doses for nonperforated cases and antibiotics after discharge for perforated cases. Mann-Whitney and Fisher's exact tests were performed. RESULTS Laparoscopic appendectomy was performed in 748 children before (PRE) and in 814 children after (POST) protocol implementation. Perforation rates were similar (POST 21.5 vs. PRE 21.8%, p=0.90). For nonperforated appendicitis, postoperative antibiotics were reduced (median 0 [IQR 0-0] vs. 3 [0-5] doses, p<0.001), and more patients were discharged less than 24 h after surgery (65.7 vs. 40.9%, p<0.001). Fewer patients with perforated appendicitis underwent PICC placement (8.6 vs. 21.0%, p=0.002), and fewer patients were prescribed antibiotics on discharge (33.7 vs. 89.0%, p<0.001). There were no differences between groups for complication, readmission, or return to ED rates. CONCLUSION For children with acute appendicitis, a standardized protocol can safely reduce unnecessary antibiotics and decrease length of stay. Furthermore, the judicious use of antibiotics does not increase SSI, readmission, or overall complication rates. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Avery C Rossidis
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Erin G Brown
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - K Joy Payton
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Peter Mattei
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
| |
Collapse
|
23
|
Svetanoff WJ, Oyetunji TA, St Peter SD. Response regarding: "Intra-abdominal Abscess After Appendectomy-Are Drains Necessary in All Patients?". J Surg Res 2020; 256:701-702. [PMID: 32917389 DOI: 10.1016/j.jss.2020.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri.
| |
Collapse
|
24
|
Mennie N, Panabokke G, Chang A, Tanny ST, Cheng W, Pacilli M, Ferguson P, Nataraja RM. Are Postoperative Intravenous Antibiotics Indicated After Laparoscopic Appendicectomy for Simple Appendicitis? A Prospective Double-blinded Randomized Controlled Trial. Ann Surg 2020; 272:248-252. [PMID: 32675537 DOI: 10.1097/sla.0000000000003732] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND There is limited evidence for the use of postoperative antibiotics for simple appendicitis (SA) in children. Our aim was to conduct a prospective double-blinded randomized controlled trial to investigate this after a laparoscopic appendicectomy. METHODS Following ethical approval, children (≤16 years) undergoing appendicectomy were recruited at a single institution. Patients were randomized intraoperatively to receive either 2 postoperative intravenous doses of placebo or antibiotics (Abx). All patients received a dose of Abx at induction of anesthesia. Primary outcome was the incidence of postoperative wound infection (WI), and secondary outcome was the incidence of intra-abdominal abscess formation. Data are reported as number of cases (%), median (range), relative risk, and analyzed using Mann Whitney U test, Chi-square test, as appropriate, a P-value ≤0.05 was considered significant. RESULTS A total of 304 patients were randomized. Sixty-one were subsequently excluded due to protocol violations or recruitment errors; therefore, 243 were included in the final analysis. One hundred twenty-two patients received placebo and 121 Intravenous Abx. There was no difference between the sex (50F/72 M vs 47F/74 M, P = 0.8), median age (12.4 vs 12.2 years, P = 0.5), and postoperative length of stay in a hospital (27.2 vs 25.6 hours, P = 0.7). There was also no difference in the preoperative blood results. A total of 9 WIs occurred: 8/122 (6.6%) placebo versus 1/121 (0.8%) Abx, P = 0.01 [relative risk for WI 7.9 (95% confidence interval: 1.0-62.4)]. There were no intra-abdominal abscess in either groups. CONCLUSIONS This prospective randomized double blinded randomized controlled trial has revealed a significant decrease in WI rates by giving 2 postoperative intravenous doses of Abx, suggesting postoperative Abx are of benefit in SA.
Collapse
Affiliation(s)
- Nicole Mennie
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Gayathri Panabokke
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Annette Chang
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Sharman Tan Tanny
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Wei Cheng
- Department of Pediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- New Century Healthcare, Hong Kong
| | - Maurizio Pacilli
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
- Department of Pediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Peter Ferguson
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
| | - Ramesh M Nataraja
- Department of Pediatric Surgery, Urology & Surgical Simulation, Monash Children's Hospital, Melbourne, Australia
- Department of Pediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| |
Collapse
|
25
|
Ferguson DM, Parker TD, Arshad SA, Garcia EI, Hebballi NB, Tsao K. Standardized Discharge Antibiotics May Reduce Readmissions in Pediatric Perforated Appendicitis. J Surg Res 2020; 255:388-395. [PMID: 32615311 DOI: 10.1016/j.jss.2020.05.086] [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: 02/28/2020] [Revised: 04/21/2020] [Accepted: 05/24/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Based on limited evidence, the American Pediatric Surgical Association recommends 5-7 d of postoperative antibiotics in perforated appendicitis for preventing intra-abdominal abscess (IAA). In 2015, our institutional clinical practice guideline was modified to standardize prescription for 7 additional days of oral antibiotics after discharge. We hypothesized that prescribing oral antibiotics after discharge would be associated with fewer complications in perforated appendicitis. MATERIALS AND METHODS A retrospective cohort study was conducted of pediatric (younger than 18 y) patients who underwent laparoscopic appendectomy for perforated appendicitis (August 1, 2012-April 30, 2019). Patients diagnosed with IAA before discharge or with a postoperative length of stay ≥8 d were excluded. Patient outcomes were compared prestandardization and poststandardization of discharge antibiotics. RESULTS Of 617 patients, 212 (34.5%) were admitted prestandardization and 404 (65.5%) poststandardization. Overall, 409 patients (66.3%) received discharge antibiotics. The median total postoperative antibiotic duration was 4 d (interquartile range, 3-5) prestandardization versus 11 d (interquartile range, 10-12) poststandardization (P < 0.001). Prestandardization patients had a higher rate of IAA (8.9% versus 4.5%, P = 0.03) and were readmitted more frequently (13.1% versus 6.4%, P = 0.005). On adjusted analysis, admission poststandardization was associated with reduced odds of IAA (odds ratio, 0.51; 95% confidence interval, 0.25-1.06), but the relationship was imprecise. Admission poststandardization was significantly associated with reduced adjusted odds of readmission (odds ratio, 0.46; 95% confidence interval, 0.25-0.85). CONCLUSIONS Prescription for seven additional days of oral antibiotics after discharge was associated with reduced odds of readmission in pediatric perforated appendicitis. This population may benefit from a longer postoperative antibiotic course than currently recommended.
Collapse
Affiliation(s)
- Dalya M Ferguson
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Tayler D Parker
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Seyed A Arshad
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas
| | - Elisa I Garcia
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Nutan B Hebballi
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas; Children's Memorial Hermann Hospital, Houston, Texas.
| |
Collapse
|
26
|
Currow C, Patel K, Askari A, Rabie M, Aly M, Aker M. Current technical surgical practice of emergency appendicectomy: a cross-sectional survey of surgical registrars in the UK. Ann R Coll Surg Engl 2020; 102:606-610. [PMID: 32501113 DOI: 10.1308/rcsann.2020.0123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Appendicectomy remains one of the most commonly performed procedures in general surgery. The aim of this study was to explore variation in operative techniques of an appendicectomy among surgical registrars in England. MATERIALS AND METHODS An anonymised survey was sent out to surgical registrars in the UK via email and social media. Subgroup analyses were performed comparing respondents based on their level of seniority and subspecialty background. RESULTS A total of 168 respondents completed the survey, of whom 77.4% (130/168) were specialty trainees years 3-8 and 44.6% (75/168) were colorectal trainees. The majority (98.8%) preferred a laparoscopic approach to appendicectomy. Overall, 73.2% opted to use diathermy to divide an uninflamed mesoappendix. Half of the respondents (50%) preferentially used diathermy to control the appendicular artery, followed by 44% preferring use of metal or polymeric clips. The appendicular stump was most often secured with Endoloops (85.7%) when removing a macroscopically uninflamed appendix but less readily used in the visibly inflamed appendix (75.6%, p = 0.01). Colorectal and upper gastrointestinal registrars were more likely to use diathermy on the mucosa of the appendix stump compared with other subspecialties (p = 0.03). The majority (82.1%) of respondents extracted the appendix via a retrieval bag. Regarding skin closure, most respondents (69%) adopted absorbable subcuticular sutures. Preferential duration of postoperative antibiotic use following appendicectomy for complicated appendicitis varied among the respondents. CONCLUSION There are similarities and differences across surgical registrars in terms of technical practice in appendicectomy, partially attributed to prior experience and training.
Collapse
Affiliation(s)
- C Currow
- Luton and Dunstable Hospital, Luton, United Kingdom
| | - K Patel
- Luton and Dunstable Hospital, Luton, United Kingdom
| | - A Askari
- Luton and Dunstable Hospital, Luton, United Kingdom
| | - M Rabie
- Ain Shams University, Cairo, Egypt
| | - M Aly
- Lister Hospital, Stevenage, United Kingdom
| | - M Aker
- West Suffolk Hospital, Bury St Edmunds, United Kingdom
| | | |
Collapse
|
27
|
Krah NM, Bardsley T, Nelson R, Esquibel L, Crosby M, Byington CL, Pavia AT, Hersh AL. Economic Burden of Home Antimicrobial Therapy: OPAT Versus Oral Therapy. Hosp Pediatr 2020; 9:234-240. [PMID: 30885919 DOI: 10.1542/hpeds.2018-0193] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is increasing evidence that outpatient parenteral antimicrobial therapy (OPAT) is overused for children and that outcomes with oral therapy are equivalent. Our objective was to compare economic burden between OPAT and oral therapy, accounting for direct and indirect costs and caregiver quality of life (QoL). METHODS We conducted a prospective cohort study of caregivers for children after hospitalization who were treated with prolonged antimicrobial therapy. We collected data about missed work and school and time spent administering therapy. Caregivers completed the Pediatric Quality of Life Inventory to assess QoL. Clinical information included length of stay, treatment indication, and type of therapy (OPAT versus oral therapy). Direct medical costs were obtained by using a microcosting system and accounted for medication, supplies, and home-nursing visits. The primary cost outcome was the mean daily cost of therapy. Multivariable models were developed to adjust for potential confounders. RESULTS Two hundred and twelve caregivers completed surveys: 123 (58%) for oral therapy and 89 (42%) for OPAT. Caregivers administering OPAT reported more missed work, missed school for their children, time with daily medication administration (90 vs 6 minutes; P < .01) and lower QoL scores (77.8 vs 68.9) than caregivers administering oral therapy. The mean daily cost was $65 (95% confidence interval: $51-$78) for OPAT and $7 (95% confidence interval: $4-$9) for oral therapy. Relative differences in cost and QoL between groups did not change after model adjustment. CONCLUSIONS The overall burden of OPAT is substantially higher than that of oral therapy, including higher direct and indirect costs and greater impact on caregiver QoL. These findings strongly support efforts to use oral therapy in place of OPAT when clinically appropriate.
Collapse
Affiliation(s)
- Nathan M Krah
- Infectious Disease, Department of Pediatrics, School of Medicine and
| | - Tyler Bardsley
- Divisions of Epidemiology and.,Study Design and Biostatistics Center, University of Utah, Salt Lake City, Utah
| | - Richard Nelson
- Divisions of Epidemiology and.,Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Lawanda Esquibel
- Infectious Disease, Department of Pediatrics, School of Medicine and
| | - Mark Crosby
- Intermountain Homecare Pharmacy, Intermountain Healthcare, Salt Lake City, Utah; and
| | | | - Andrew T Pavia
- Infectious Disease, Department of Pediatrics, School of Medicine and
| | - Adam L Hersh
- Infectious Disease, Department of Pediatrics, School of Medicine and
| |
Collapse
|
28
|
Intravenous versus intravenous/oral antibiotics for perforated appendicitis in pediatric patients: a systematic review and meta-analysis. BMC Pediatr 2019; 19:407. [PMID: 31684906 PMCID: PMC6827245 DOI: 10.1186/s12887-019-1799-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023] Open
Abstract
Background The use of oral (PO) antibiotics following a course of certain intravenous (IV) antibiotics is proposed in order to avoid the complications of IV medications and to decrease the cost. However, the efficacy and safety of sequential IV/PO antibiotics is unclear and requires further study. Methods The databases, including PubMed, EMBASE and Cochrane Library, were searched. Studies comparing outcomes in patients with perforated appendicitis receiving sequential IV/PO and PO antibiotics therapy were screened. The Newcastle-Ottawa Scale (NOS) and the Jadad score were used to evaluate the quality of the cohort and the randomized controlled portions of the trial, respectively. Statistical heterogeneity was assessed using the I2 value. A fixed or random-effect model was applied according to the I2 value. Results Five controlled studies including a total of 580 patients were evaluated. The pooled estimates revealed that sequential IV/PO antibiotic therapy did not increase the risk of complications, with a risk ratio (RR) of 0.97 (95% CI 0.51–1.83, P = 0.93) for postoperative abscess, 1.04 (95% CI 0.25–4.36, P = 0.96) for wound infection and 0.62 (95% CI 0.33–1.16, P = 0.13) for readmission. Conclusions Our study demonstrates that sequential IV/PO antibiotic therapy is noninferior to IV antibiotic therapy regarding postoperative abscess, wound infection and readmission.
Collapse
|
29
|
Holguín-Sanabria DA, Perilla-López MÁ, Castañeda-Espinosa S, Jaimes-de La Hoz P, Aragón S, Valero JJ, Molina ID, Fierro-Ávila F. Prevalence of organ-space surgical site infections after appendectomy for ruptured appendix in children. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n4.64434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Appendicitis can be classified as non-perforated and perforated; based on such classification, the reported organ-space surgical site infection (OS-SSI) rate is 0.8% and 18%, respectively.Objective: To establish the prevalence of OS-SSI in patients with perforated appendicitis treated in a pediatric hospital in 2012.Materials and methods: Retrospective, observational and descriptive study conducted at Fundación Hospital Pediátrico La Misericordia, with a random sample of 200 patients, of which 160 met the inclusion criteria.Results: 20 patients (12.5%) presented with OS-SSI and all of them received antibiotic treatment; 70% did not require abscess drainage. Patients ≥8 years of age had 5 times more abscesses than younger ones (17.6% vs. 3.4%). OS-SSI was found in 33% of patients with free fecalith and in 50% of the patients who required postoperative management at the ICU vs. 9.5% of the patients who received management in the intermediate care unit and the inpatient hospital floors. The total rate of surgical site infection was 24.3% (11.8% superficial, 0% deep and 12.5% organ-space).Conclusions: The prevalence of OS-SSI found here is lower than what has been reported in the literature. Being 8 years or older and having free fecalith are risk factors to develop this type of infection. The higher frequency of OS-SSI in patients treated at the ICU during the post-operative period observed here suggests that this condition may be associated with septic shock.
Collapse
|
30
|
Child J, Chen X, Mistry RD, Somme S, MacBrayne C, Anderson PL, Jones RN, Parker SK. Pharmacokinetic and Pharmacodynamic Properties of Metronidazole in Pediatric Patients With Acute Appendicitis: A Prospective Study. J Pediatric Infect Dis Soc 2019; 8:297-302. [PMID: 29788329 DOI: 10.1093/jpids/piy040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 04/24/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND Metronidazole is traditionally dosed every 6-8 hours even though in adults it has a long half-life, concentration-dependent killing, and 3-hour postantibiotic effect. Based on this logic, some pediatric hospitals adopted once-daily dosing for appendicitis, despite limited pharmacokinetics-pharmacodynamics (PK/PD) in children. We studied pediatric patients with appendicitis given metronidazole once daily to determine whether this dosing would meet target area under the curve (AUC)/minimum inhibitory concentration (MIC) ratio of ≥70 for Bacteroides fragilis. METHODS One hundred pediatric patients aged 4-17 years had an average of 3 blood draws per patient during the first 24 hours after a 30 mg/kg per dose of intravenous metronidazole. Concentrations of drug were determined using validated liquid chromatography and tandem mass spectrometry. A NONMEM model was constructed for determining PK, followed by Monte Carlo simulations to generate a population of plasma concentration-time AUC of metronidazole and hydroxy-metronidazole. RESULTS Simulated AUC values met target attainment (AUC/MIC ratio of ≥70 to B fragilis MICs) for 96%-100% of all patients for an MIC of 2 mcg/mL. For MICs of 4 and 8 mcg/mL, target attainment ranged from 61% to 97% and 9% to 71%, respectively. Areas under the curve were similar to that of adults receiving 1000 mg and 1500 mg q24, or 500 mg q8 hours. CONCLUSIONS Metronidazole, 30 mg/kg per dose, once daily achieved AUC target attainment for B fragilis with an MIC of 2 mcg/mL or less in pediatric appendicitis patients. Based on this and studies in adults, there does not seem to be any PK/PD advantage of more frequent dosing in this population.
Collapse
Affiliation(s)
- Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Xinhui Chen
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Stig Somme
- Division of General, Thoracic, and Fetal Pediatric Surgery, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Christine MacBrayne
- Department of Pharmacy, Children's Hospital Colorado, Aurora.,University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | - Peter L Anderson
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | | | - Sarah K Parker
- Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, Aurora
| |
Collapse
|
31
|
Bonasso PC, Dassinger MS, Wyrick DL, Smith SD, Burford JM. Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis. Am J Surg 2019; 217:1099-1101. [PMID: 30639131 DOI: 10.1016/j.amjsurg.2018.12.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
|
32
|
OPAT for avoidance of hospitalisation in children. THE LANCET. INFECTIOUS DISEASES 2019; 19:450-451. [PMID: 30853251 DOI: 10.1016/s1473-3099(19)30043-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/29/2019] [Indexed: 11/21/2022]
|
33
|
Efficacy of oral antibiotics in children with post-operative abscess from perforated appendicitis. Pediatr Surg Int 2019; 35:329-333. [PMID: 30506487 DOI: 10.1007/s00383-018-4424-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). Typically, intravenous antibiotics by a peripherally inserted venous catheter are utilized to treat the abscess. We sought to evaluate the role of oral antibiotics in this population. METHODS This is a retrospective review conducted of children between January 2005 and September 2015 with a PIAA. Demographics, clinical course, complications, and follow-up were analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral vs IV antibiotics after diagnosis of PIAA. RESULTS 103 children were included. Days of symptoms prior to admission were 3.2 ± 2.3 days with a WBC of 17.9 ± 6.4. Median time to diagnosis of PIAA from appendectomy was 7 days (7, 10). Mean total length of stay was 10 ± 3.4 days. 42% were treated with oral antibiotics (n = 43) versus 58% IV antibiotics (n = 60) at the time of discharge. We found a significant increase in total length of hospital stay (9.1 vs 10.7, p = 0.02) and number of medical encounters required for treatment (3.4 vs 4.4, p ≤ 0.01) in the IV group. CONCLUSIONS PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivalent outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required.
Collapse
|
34
|
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.
Collapse
|
35
|
Arnold MR, Wormer BA, Kao AM, Klima DA, Colavita PD, Cosper GH, Heniford BT, Schulman AM. Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial. Pediatr Surg Int 2018; 34:1257-1268. [PMID: 30218170 DOI: 10.1007/s00383-018-4343-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis. METHODS This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared. RESULTS Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001). CONCLUSION Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.
Collapse
Affiliation(s)
- Michael R Arnold
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Blair A Wormer
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Angela M Kao
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - David A Klima
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Paul D Colavita
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Graham H Cosper
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA.,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA.,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA
| | - Brant Todd Heniford
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Andrew M Schulman
- Levine Children's Hospital, Carolinas Healthcare System, 1000 Blythe Blvd., Charlotte, NC, 28203, USA. .,Hemby Children's Hospital, Novant Health, 200 Hawthorne Ln., Charlotte, NC, 28204, USA. .,Pediatric Surgical Associates, 1900 Randolph Road, Suite 210, Charlotte, NC, 28207, USA.
| |
Collapse
|
36
|
Importance of Compliance Audits for a Pediatric Complicated Appendicitis Clinical Practice Guideline. J Med Syst 2018; 42:257. [PMID: 30406316 DOI: 10.1007/s10916-018-1117-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/02/2018] [Indexed: 11/25/2022]
|
37
|
Anderson KT, Bartz-Kurycki MA, Kawaguchi AL, Austin MT, Holzmann-Pazgal G, Kao LS, Lally KP, Tsao K. Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe? J Am Coll Surg 2018; 227:247-254. [PMID: 29680415 DOI: 10.1016/j.jamcollsurg.2018.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
|
38
|
Zens TJ, Rogers AP, Riedesel EL, Leys CM, Ostlie DJ, Woods MA, Gill KG. The cost effectiveness and utility of a "quick MRI" for the evaluation of intra-abdominal abscess after acute appendicitis in the pediatric patient population. J Pediatr Surg 2018; 53:1168-1174. [PMID: 29673611 DOI: 10.1016/j.jpedsurg.2018.02.078] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Contrast-enhanced CT remains the first-line imaging for evaluating postoperative abscess (POA) after appendicitis. Given concerns of ionizing radiation use in children, we began utilizing quick MRI to evaluate POA and summarize our findings in this study. MATERIALS AND METHODS Children imaged with quick MRI from 2015 to 2017 were compared to children evaluated with CT from 2012 to 2014 using an age and weight matched case-control model. Radiation exposure, size and number of abscesses, length of exam, drain placement, and patient outcomes were compared. RESULTS There was no difference in age or weight (p>0.60) between children evaluated with quick MRI (n=16) and CT (n=16). Mean imaging time was longer (18.2±8.5min) for MRI (p<0.001), but there was no difference in time from imaging order to drain placement (p=0.969). No children required sedation or had non-diagnostic imaging. There were no differences in abscess volume (p=0.346) or drain placement (p=0.332). Thirty-day follow-up showed no difference in readmissions (p=0.551) and no missed abscesses. Quick MRI reduced imaging charges to $1871 from $5650 with CT. CONCLUSION Quick MRI demonstrated equivalent outcomes to CT in terms of POA detection, drain placement, and 30-day complications suggesting that MRI provides an equally effective, less expensive, and non-radiation modality for the identification of POA. TYPE OF STUDY Retrospective Case-Control Study. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Tiffany J Zens
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Andrew P Rogers
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Erica L Riedesel
- Division of Pediatric Radiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | | | - Michael A Woods
- Division of Interventional Radiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Kara G Gill
- Division of Pediatric Radiology, Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI; American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison, WI.
| |
Collapse
|
39
|
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.
Collapse
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
| |
Collapse
|
40
|
Abstract
BACKGROUND Complicated appendicitis, characterized by perforation and/or peritonitis, is common in children, and late infectious complications are frequent. The best antibiotic treatment approach is unknown, resulting in substantial variation in care. We evaluated the effects of 2 successive interventions, an antimicrobial stewardship program (ASP) and a condition-specific clinical practice guideline (CPG), on antimicrobial utilization and patient outcomes in these patients. METHODS The ASP at our institution was begun in March 2012. The CPG, a standardized antibiotic treatment, was implemented in July 2013. We reviewed every case of complicated appendicitis managed with early appendectomy between January 2011 and October 2014. Patients were thus divided into 3 eras based on their exposure to the following: (1) neither intervention, (2) ASP only or (3) both ASP and CPG. We compared measures of antibiotic utilization and clinical outcomes among the 3 eras. RESULTS A total of 313 patients were included in the study: 91 exposed to neither intervention; 100 exposed to only the ASP; and 122 exposed to both interventions. With ASP implementation, there were declines in the use of unnecessarily broad or toxic antibiotic regimens. With CPG implementation, there was a decrease in total antibiotic utilization and discharges with intravenous antibiotics. Compliance with CPG-recommended antibiotics exceeded 90%. There was no significant change in overall adverse events; there was a decline in the incidence of surgical-site infections in patients exposed to both interventions. CONCLUSIONS Complicated appendicitis is an important target for antimicrobial stewardship and quality improvement efforts. A condition-specific CPG can improve both antimicrobial utilization and clinical outcomes.
Collapse
|
41
|
Poola AS, Oyetunji TA, Holcomb GW, St Peter SD. Maturation of effect size during enrollment of prospective randomized trials. J Surg Res 2018; 223:34-38. [DOI: 10.1016/j.jss.2017.06.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/17/2017] [Accepted: 06/19/2017] [Indexed: 11/26/2022]
|
42
|
Abstract
BACKGROUND AND OBJECTIVE Outpatient parenteral antimicrobial therapy (OPAT) provides numerous benefits but may pose unique risks in children. We aimed to determine rates of OPAT antimicrobial- and intravenous access-related complications and their associations with specific antimicrobials and type of intravenous access in pediatric patients. METHODS Observational cohort study of patients receiving OPAT from August 2008 to May 2015 cared for by the Infectious Diseases service at a tertiary children's hospital. Primary outcome was antimicrobial discontinuation (AD) because of OPAT-associated complications. Secondary outcomes were unplanned outpatient healthcare visits and readmissions from OPAT-associated complications. RESULTS Seven hundred and seven intravenous antimicrobials were prescribed in 540 cases. Nondevice-associated musculoskeletal infection was the most common diagnosis (39%). Ceftriaxone (30%), cefazolin (27%) and vancomycin (22%) were the most commonly used antimicrobials. Complications led to AD, ≥1 unplanned outpatient healthcare visit and ≥1 readmission in 23%, 30% and 17% of cases, respectively. Compared with use of ceftriaxone, use of oxacillin was associated with a significantly higher risk of AD because of any antimicrobial-related complication [hazard ratio (HR), 3.3; 95% confidence interval (CI): 1.2-9.7) and because of hepatic transaminitis (HR, 32.8; 95% CI: 4.02-268.2). Subjects treated with intravenous clindamycin (HR, 2.6; 95% CI: 1.1-5.8) and with a peripherally inserted central catheter (HR, 2.6; 95% CI: 1.04-6.3) were more likely to have unplanned outpatient visits. CONCLUSIONS Use of oxacillin during OPAT was associated with higher rate of AD. Patients treated with clindamycin and those with a peripherally inserted central catheter had higher rates of unplanned outpatient visits. Providers should strongly consider alternative treatment options when possible.
Collapse
|
43
|
Shang Q, Geng Q, Zhang X, Guo C. The efficacy of combined therapy with metronidazole and broad-spectrum antibiotics on postoperative outcomes for pediatric patients with perforated appendicitis. Medicine (Baltimore) 2017; 96:e8849. [PMID: 29381994 PMCID: PMC5708993 DOI: 10.1097/md.0000000000008849] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to evaluate the efficacy of combined therapy with metronidazole and broad-spectrum antibiotics for patients with perforated appendicitis who underwent surgical intervention.Broad-spectrum antibiotic therapy is warranted in the treatment of perforated appendicitis. Metronidazole has been used as anaerobic antimicrobial therapy. However, few studies about the use of metronidazole in perforated appendicitis have been reported.The medical records of 249 patients treated with metronidazole combined with broad-spectrum antibiotics following perforated appendicitis surgery were reviewed retrospectively and compared with the medical records of 149 patients treated only with broad-spectrum antibiotics. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including postoperative complications and length of hospital stay, were compared between the 2 groups.No differences were found between the use of combined therapy with metronidazole and the use of solely broad-spectrum antibiotic agents with regard to postoperative duration of intravenous antibiotic treatment (6.8 ± 1.3 vs 7.9 ± 2.1 days, respectively, P = .18), inflammation variables at POD 5 (white blood cell [WBC] [risk ratio [RR], 1.06; 95% confidence interval [CI], 0.67-1.93, P = .15] and C-reactive protein [CRP] [RR, 1.18; 95% CI, 0.73-2.25, P = .36]) (Table 2), and the mean postoperative length of hospital stay (LOS) (RR, 0.68, 95% CI, 0.41-0.94, P = .41). There were also no differences in the incidence of postoperative complications, including the intra-abdominal or pelvic abscess rate (7[7.1%] vs 9[9.2%], respectively, P = .40), the incidence of wound infection (14[14.3%] vs 15[15.3%], respectively, P = .50), and the 30-day readmission rate (9[9.2%] vs 12[12.2%], respectively, P = .32).Regarding overall postoperative outcomes and complications, our study demonstrated no beneficial clinical effects of metronidazole administration in patients with perforated appendicitis who underwent surgical intervention. Therefore, metronidazole is not indicated when broad-spectrum antibiotics such as aminopenicillins with β-lactam inhibitors or carbapenems and select cephalosporins are used.
Collapse
Affiliation(s)
- Qingjuan Shang
- Department of Pathology, Linyi People's Hospital, Linyi, Shandong Province
| | - Qiankun Geng
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing
| | - Xuebing Zhang
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing
| | - Chunbao Guo
- Department of Pediatric General Surgery, Children's Hospital, Chongqing Medical University, Chongqing
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| |
Collapse
|
44
|
Lima AP, Vieira FJ, Oliveira GPDEM, Ramos PDS, Avelino ME, Prado FG, Salomão G, Silva FC, Rodrigues JVL. Clinical-epidemiological profile of acute appendicitis: retrospective analysis of 638 cases. Rev Col Bras Cir 2017; 43:248-53. [PMID: 27679944 DOI: 10.1590/0100-69912016004009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 06/21/2016] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE to describe the clinical and epidemiological profile of acute appendicitis (AA) of the patients treated at a referral center in the Juiz de Fora macro-region, Minas Gerais State, Brazil. METHODS we conducted a retrospective, observational study in the Dr. Mozart Geraldo TeixeiraEmergency Hospital. We selected 638 patients diagnosed with AA, and analyzed the variables gender, age, evolutionary phase, length of hospital stay, pathological diagnosis, use of antibiotics, use of drains, complications and mortality. RESULTS AA was more prevalent in young adults (19-44 years) and males (65.20%). The mean hospital stay was seven days and phase II was the most prevalent. We found the histopathological diagnosis of primary tumor of the appendix in six patients (0.94%), adenocarcinoma being the most common histologic type (66.7%). Regarding the use of antibiotics, 196 patients underwent antibiotic prophylaxis and 306 received antibiotic therapy. Eighty-one patients used some kind of drain, for an average of 4.8 days. Seventeen patients died (2.67%), predominantly males (70.59%), with mean age of 38.47 years. CONCLUSION AA has a higher prevalence in males and young adults. The length of stay is directly associated with the evolutionary phase. The most common complication is infection of the surgical site. Mortality in our service is still high when compared with developed centers. OBJETIVO avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes. MÉTODOS estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período. RESULTADOS a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses. CONCLUSÃO de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.
Collapse
Affiliation(s)
- Amanda Pereira Lima
- - Faculty of Medical Sciences and Health, Juiz de Fora (SUPREME), Juiz de Fora, MG, Brazil
| | - Felipe José Vieira
- - Dr. Mozart Geraldo Teixeira Emergency Hospital, Juiz de Fora, MG, Brazil.,- Faculty of Medical Sciences and Health, Juiz de Fora (SUPREME), Juiz de Fora, MG, Brazil
| | | | | | - Marielle Elisa Avelino
- - Faculty of Medical Sciences and Health, Juiz de Fora (SUPREME), Juiz de Fora, MG, Brazil
| | - Felipe Garcia Prado
- - Faculty of Medical Sciences and Health, Juiz de Fora (SUPREME), Juiz de Fora, MG, Brazil
| | - Gilson Salomão
- - Dr. Mozart Geraldo Teixeira Emergency Hospital, Juiz de Fora, MG, Brazil
| | | | | |
Collapse
|
45
|
Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified? Ann Surg 2017; 266:361-368. [PMID: 27429024 DOI: 10.1097/sla.0000000000001923] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge. BACKGROUND Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited. METHODS We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting. RESULTS In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05-2.88; risk difference: 4.0%, 95% CI 0.4-7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44-3.11; risk difference: 9.4%, 95% CI 4.7-14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%). CONCLUSIONS Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.
Collapse
|
46
|
Sadraei-Moosavi SM, Nikhbakhsh N, Darzi AA. Postoperative antibiotic therapy after appendectomy in patients with non-perforated appendicitis. CASPIAN JOURNAL OF INTERNAL MEDICINE 2017; 8:104-107. [PMID: 28702149 PMCID: PMC5494044 DOI: 10.22088/cjim.8.2.104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Appendectomy intra-abdominal is the most frequently performed emergency surgery. This study was conducted to determine the role of postoperative antibiotics in reducing surgical site infections (SSIs) and abscess formation after open appendectomy. METHODS In the Department of Surgery, Shahid Beheshti Hospital, Babol, Iran, from October 2013 to October 2014 one hundred and fifty two patients, who underwent appendectomy for nonperforated appendicitis (NPA) and fulfilled the selection criteria, were randomized into two groups. Group A patients received a single dose of preoperative antibiotics (ceftriaxone and metronidazole) and group B patients received the same regimen, in addition, antibiotics were administered 24 hours postoperatively. Patients of both groups were followed-up for 30 days to assess the postoperative infectious complications. RESULTS Both groups comprised 76 patients, as well both groups were compared in baseline characteristics. Statistically, there was no significant difference in rates of SSIs between both groups. None of the patients developed intra-abdominal collection. CONCLUSION Single dose of preoperative antibiotics (ceftriaxone and metronidazole) was sufficient in reducing SSIs after appendectomy for NPA. Postoperative antibiotics did not add an appreciable clinical benefit in these patients.
Collapse
Affiliation(s)
| | - Novin Nikhbakhsh
- Cancer Research Center, Health Research Institue, Babol University of Medical Sciences, Babol, Iran.,Department of Surgery, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Ali-Asghar Darzi
- Cancer Research Center, Health Research Institue, Babol University of Medical Sciences, Babol, Iran.,Department of Surgery, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran
| |
Collapse
|
47
|
Chen CL, Chao HC, Kong MS, Chen SY. Risk Factors for Prolonged Hospitalization in Pediatric Appendicitis Patients with Medical Treatment. Pediatr Neonatol 2017; 58:223-228. [PMID: 27477876 DOI: 10.1016/j.pedneo.2016.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/02/2016] [Accepted: 02/26/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND With effective antibiotics against enteric flora and computed tomography-guided drainage for abscesses, the initial use of nonoperative therapy for children with appendicitis has increased both in recent reports and at our hospital. However, it has been reported that these patients have a relatively longer hospital stay and that their treatment is more expensive than those who undergo aggressive surgical intervention. METHODS This was a retrospective cohort study based in a single medical center. A systemic chart review was conducted to identify risk factors for prolonged hospitalization in pediatric appendicitis patients not initially undergoing surgical treatment. Patient demographics, clinical symptoms, duration of symptoms, laboratory findings, imaging findings, complications, and length of hospital stay were analyzed. Logistic regression analysis was used to identify significant predictors of prolonged hospitalization (≥15 days) and readmission. RESULTS One hundred and twenty-five patients were recruited in this study, of whom 53 (42.4%) had prolonged hospitalization. The values of serum C-reactive protein (CRP) were significantly higher in patients with prolonged hospitalization compared with those without prolonged hospitalization (203 ± 108.6 mg/L vs. 140 ± 93.0 mg/L, p = 0.001). Risk factors of prolonged hospitalization were serum CRP >150 mg/L (35/53 vs. 28/72, p = 0.001), abscess formation (38/53 vs. 35/72, p = 0.008), and multiple abscesses (10/53 vs. 1/72, p = 0.001). Under multivariate analysis, CRP >150 mg/L (odds ratio=1.004, p = 0.0334) and multiple abscesses (odds ratio = 8.788, p = 0.044) were two independent predictors for prolonged hospitalization. CONCLUSION Marked elevation of serum CRP (>150 mg/L) and multiple abscesses are two independent risk factors for prolonged hospitalization in children with appendicitis who are initially treated nonoperatively.
Collapse
Affiliation(s)
- Ching-Lun Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan
| | - Hsun-Chin Chao
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan; Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan.
| | - Man-Shan Kong
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan; Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan
| | - Shih-Yen Chen
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Children's Medical Center, Chang Gung Memorial Hospital, Guishan District, Taoyuan City, Taiwan; Chang Gung University College of Medicine, Guishan District, Taoyuan City, Taiwan
| |
Collapse
|
48
|
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: 321] [Impact Index Per Article: 45.9] [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.
Collapse
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
| |
Collapse
|
49
|
Sun F, Wang H, Zhang F, Zhang X, Xing Z, Zhang S, Zhang H, Wang Y. Copious Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Complicated Appendicitis in Adults. J INVEST SURG 2017; 31:342-346. [PMID: 28485994 DOI: 10.1080/08941939.2017.1319995] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Fengbo Sun
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
| | - He Wang
- Qingdao Sixth People's Hospital, Qingdao, China
| | - Fengjuan Zhang
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinming Zhang
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
| | | | - Shenglin Zhang
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
| | | | - Ye Wang
- The Affiliated Qingdao Hiser Hospital of Qingdao University, Qingdao, China
| |
Collapse
|
50
|
Goldman JL, Richardson T, Newland JG, Lee B, Gerber JS, Hall M, Kronman M, Hersh AL. Outpatient Parenteral Antimicrobial Therapy in Pediatric Medicaid Enrollees. J Pediatric Infect Dis Soc 2017; 6:65-71. [PMID: 26803327 PMCID: PMC5907854 DOI: 10.1093/jpids/piv106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/14/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT. METHODS We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was identified by capturing children with claims data indicating home infusion therapy for an intravenous antimicrobial. We characterized OPAT use by describing patient demographics, diagnoses, and antimicrobials prescribed. We categorized an antimicrobial as highly bioavailable if ≥80% systemic exposure was expected from the peroral dose. We also determined the percentage of OPAT recipients in whom a follow-up healthcare encounter occurred during the OPAT episode in either the emergency department or as a hospital admission. We reviewed the primary diagnoses associated with these healthcare encounters to determine whether it was related to OPAT. RESULTS We identified 3433 OPAT episodes in 2687 patients. A total of 4774 antimicrobials were prescribed during these episodes. Ceftriaxone and vancomycin were the most commonly prescribed antimicrobials. Highly bioavailable antimicrobials accounted for 34% of antimicrobials used for OPAT. An emergency department visit or hospital admission occurred during 38% of OPAT episodes, among which 61% were OPAT-related. CONCLUSIONS The high rate of medical encounters associated with OPAT in this cohort and the common prescribing of highly bioavailable antimicrobials underscore the opportunities for antimicrobial stewardship of pediatric OPAT.
Collapse
Affiliation(s)
- Jennifer L. Goldman
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | | | - Jason G. Newland
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | - Brian Lee
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | | | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | | | - Adam L. Hersh
- University of Utah School of Medicine, Salt Lake City
| |
Collapse
|