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Doshi N, Bandyopadhyay S, Green M, Richardson E, Komber A, Chen SE, Shah R, Lakhoo K. The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review. J Pediatr Surg 2024:S0022-3468(24)00173-8. [PMID: 38565474 DOI: 10.1016/j.jpedsurg.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 02/09/2024] [Accepted: 03/09/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach. METHODS A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769). RESULTS Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)). CONCLUSION Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Neel Doshi
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom.
| | - Soham Bandyopadhyay
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Madeline Green
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Edward Richardson
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Ahmad Komber
- Usher Institute, University of Edinburgh, 450 Old Dalkeith Rd, Edinburgh EH16 4SS, United Kingdom
| | - Si Emma Chen
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Rahul Shah
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
| | - Kokila Lakhoo
- University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom
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Fuad M, Modher A, Habash M. Is Routine Intra-operative Gram Stain, Culture, and Sensitivity during an Appendectomy is Effective in Decreasing the Rate of Post-operative Infective Complications? Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Organisms blamed in acute appendicitis are right predictable and very susceptible to a wide range of broad-spectrum antibiotics.
AIM: The aim of the study was to assess the clinical benefit of the routine intra-operative swab during an appendectomy in guiding antibiotic selection.
METHODS: Four hundred and thirty patients underwent appendectomy halved into two groups, each 215. In Group 1, an intra-operative swab was routinely obtained for culture/sensitivity. The results of which were reviewed for helping direct antibiotic selection. No intra-operative swabs were obtained in Group 2. Both groups were given single-dose cefotaxime and metronidazole preoperatively intravenously at the time of induction of anesthesia.
RESULTS: In swab group, 63/215 cultures (29.3%) revealed pathogens, while (70.7%) were negative or revealed isolated colonic commensals. Most cultures were negative or isolated colonic commensals. Fifty-two/63 cultures (82.54%) were sensitive to both cefotaxime and metronidazole, and only 11/63 (17.46%) reported resistant organisms to cefotaxime but not to metronidazole. Most pathogens were sensitive to empirical antibiotics. Twenty-two/215 patients (10.23%) developed infective complications, most (63.6%) had their cultures from the infected wound yielded different micro-organisms. Only 8/215 (3.72%) in the swab group needed a change in the empirical antibiotics for treating infective complications. In the non-swab group, 19/215 patients (8.83%) developed infective complications. Only 6/215 patients (2.8%) needed a change in the empirical antibiotics for treating infective complications. Collectively, only 14/430 patients (3.25%) required a change in the empirical antibiotics for treating infected wounds.
CONCLUSIONS: Routine peritoneal swabs for culture/sensitivity during appendicectomy are of no clinical value. Such practice is considered a waste of laboratory resources and money. A single prophylactic dose of antibiotics has significant role in preventing surgical site infection.
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Deodatus JAA, Paas SFE, Wagenvoort GHJ, de Kubber MM. Case report: appendicitis induced Staphylococcus aureus and Klebsiella pneumoniae bacteremia in a young healthy male. Int J Emerg Med 2021; 14:36. [PMID: 34281508 PMCID: PMC8287795 DOI: 10.1186/s12245-021-00358-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 05/23/2021] [Indexed: 12/29/2022] Open
Abstract
Background Appendicitis is one of the most frequently encountered conditions at the emergency department. Distinction is made between complicated and uncomplicated appendicitis. Complicated appendicitis may cause serious intra-abdominal infection, bacteremia, or sepsis. Emergency health providers should be highly alert to any early signs indicating such complications. Case presentation We present the case of a healthy young male with a gangrenous appendicitis, who received antibiotics and underwent appendectomy. Blood cultures showed unequivocal Staphylococcus aureus and concomitant Klebsiella pneumoniae bacteremia requiring prolonged antibiotic treatment and further diagnostic evaluation. Conclusions Although rare, appendicitis can cause Staphylococcus aureus and Klebsiella pneumoniae bacteremia with extensive implications for workup and antibiotic management. Our case stresses the importance of obtaining cultures in patients with suspicion of bacteremia given its consequences for clinical management.
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Dahlberg M, Almström M, Wester T, Svensson JF. Intraoperative cultures during appendectomy in children are poor predictors of pathogens and resistance patterns in cultures from postoperative abscesses. Pediatr Surg Int 2019; 35:341-346. [PMID: 30617968 PMCID: PMC6394779 DOI: 10.1007/s00383-018-04428-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intraoperative cultures are commonly sent in complicated appendicitis. Culture-guided antibiotics used to prevent postoperative infectious complications are debated. In this study, we describe the microbial overlap between intraoperative and abscess cultures, and antibiotic resistance patterns. METHOD A local register of a children's hospital treating children 0-15 years old with appendicitis between 2006 and 2013 was used to find cases with intraoperative cultures, and cultures from drained or aspirated postoperative intraabdominal abscesses. Culture results, administered antibiotics, their nominal coverage of the identified microorganisms, and rationales given for changes in antibiotic regimens were collected from electronic medical records. RESULTS In 25 of 35 patients who met inclusion criteria, there was no overlap between the intraoperative and abscess cultures. In 33 of 35 patients, all identified intraoperative organisms were covered with postoperative antibiotics. In 14 patients, organisms in the abscess culture were not covered by administered antibiotics. Enterococci not found in the intraoperative culture were found in 12 of 35 abscesses. We found no difference in the antibiotic coverage between rationales given for antibiotic changes. CONCLUSION The overlap between intraoperative cultures and cultures from subsequent abscesses was small. Lack of antibiotic coverage of intraoperative cultures was not an important factor in abscess formation.
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Affiliation(s)
- Martin Dahlberg
- Department of Clinical Science and Education, Department of Surgery, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden ,0000 0000 8986 2221grid.416648.9Department of Surgery, Stockholm South General Hospital (Södersjukhuset), Sjukhusbacken 10, 118 83 Stockholm, Sweden
| | - Markus Almström
- 0000 0000 9241 5705grid.24381.3cDepartment of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Women’s and Child’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Wester
- 0000 0000 9241 5705grid.24381.3cDepartment of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Women’s and Child’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Jan F. Svensson
- 0000 0000 9241 5705grid.24381.3cDepartment of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Women’s and Child’s Health, Karolinska Institutet, Stockholm, Sweden
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Uselessness of microbiological samples in acute appendicitis with frank pus: to collect or not to collect? Eur J Trauma Emerg Surg 2018; 46:835-839. [DOI: 10.1007/s00068-018-1031-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
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Frongia G, Mehrabi A, Ziebell L, Schenk JP, Günther P. Predicting Postoperative Complications After Pediatric Perforated Appendicitis. J INVEST SURG 2016; 29:185-94. [PMID: 26822038 DOI: 10.3109/08941939.2015.1114690] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA. MATERIAL AND METHODS The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions. RESULTS Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001). CONCLUSIONS Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.
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Affiliation(s)
- G Frongia
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
| | - A Mehrabi
- b Department of General , Visceral and Transplantation Surgery
| | - L Ziebell
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
| | - J P Schenk
- c Division of Pediatric Radiology, Department of Diagnostic and Interventional Radiology , University Hospital of Heidelberg , Heidelberg , Germany
| | - P Günther
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
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Peritoneal fluid culture and antibiotic treatment in patients with perforated appendicitis in a Pacific Island. Asian J Surg 2015; 38:242-6. [PMID: 25944107 DOI: 10.1016/j.asjsur.2015.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 02/12/2015] [Accepted: 03/04/2015] [Indexed: 11/19/2022] Open
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Determinants of postoperative abscess occurrence and percutaneous drainage in children with perforated appendicitis. Pediatr Surg Int 2014; 30:1265-71. [PMID: 25362478 DOI: 10.1007/s00383-014-3617-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2014] [Indexed: 01/07/2023]
Abstract
PURPOSE Postoperative abscesses after perforated appendicitis have no clear risk factors or indications for percutaneous drainage. Our study addressed these two issues. METHODS A logistic regression model was used to delineate risk factors for postoperative abscess in children with perforated appendicitis treated during a recent 5-year period. Drainage of abscess was compared to antibiotic treatment. RESULTS Postoperative abscess occurred in 42 (14.8%) of 284 patients. Higher WBC count, presence of bowel obstruction at presentation, diffuse peritonitis with a dominant abscess at surgery, and one specific surgeon were significantly associated with postoperative abscess, while fever or pain requiring narcotics at the time of abscess diagnosis was significantly associated with drainage. Compared to non-drainage, those drained had longer hospital stay including readmissions (15.9 ± 5.3 vs. 12.2 ± 4.6 days, p < 0.005) and less readmissions (9.5 vs. 33.3%, p = 0.06). Over the 5-year period, there was no increased trend in abscess occurrence (p = 0.56), but there was an increased trend in the use of percutaneous drainage (p = 0.02). CONCLUSIONS The risk of a postoperative abscess can be predicted by specific clinical characteristics, surgical findings, and treatment-related factors. Percutaneous drainage was associated with longer hospital stays, but less readmissions.
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Bansal V, Altermatt S, Nadal D, Berger C. Lack of benefit of preoperative antimicrobial prophylaxis in children with acute appendicitis: a prospective cohort study. Infection 2012; 40:635-41. [PMID: 22810888 DOI: 10.1007/s15010-012-0297-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 06/28/2012] [Indexed: 12/01/2022]
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Emil S, Gaied F, Lo A, Laberge JM, Puligandla P, Shaw K, Baird R, Bernard C, Blumenkrantz M, Nguyen VH. Gangrenous appendicitis in children: a prospective evaluation of definition, bacteriology, histopathology, and outcomes. J Surg Res 2012; 177:123-6. [PMID: 22482763 DOI: 10.1016/j.jss.2012.03.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 02/27/2012] [Accepted: 03/08/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The definition and treatment of gangrenous appendicitis are not agreed upon. We performed a prospective study in children to evaluate an objective definition of gangrenous appendicitis, as well as associated bacteriology, histopathology, and outcomes. METHODS Five staff pediatric surgeons prospectively enrolled patients in the study at the time of appendectomy if the following five criteria were met: gray or black discoloration of the appendiceal wall; absence of fecalith outside the appendix; absence of visible hole in the appendix; absence of gross purulence or fibrinous exudate remote from the appendix; and absence of intraoperative appendiceal leak. Peritoneal fluid was cultured, and a standard histopathologic review was undertaken. Persistence of fever (>37.5°C) and ileus was documented daily. Patients were continued postoperatively on ampicillin, gentamicin, and metronidazole until they tolerated diet, manifested a 24-h afebrile period, and had a normal leukocyte count. Hospital stay, readmissions, and infectious complications were recorded. The study took place over a 12-mo period. RESULTS Thirty-eight patients were enrolled, representing 17% of all patients with appendicitis treated during the year. Average age was 10.8 ± 3.5 y. Peritoneal cultures were positive in 53% of cases. Gangrene was documented histologically in 61% of specimens. Hospital stay was 3.2 ± 1.1 d. There were no postoperative infectious complications or readmissions related to the disease. Neither culture results nor histologic gangrene had a statistically significant effect on hospital stay. CONCLUSIONS An objective definition of gangrenous appendicitis is reproducible and has good histopathologic association. Recovery from gangrenous appendicitis is not influenced by culture or pathology results, and postoperative complications are rare. Limiting postoperative antibiotics to 24 h in gangrenous appendicitis may significantly decrease the cost of treatment without increasing morbidity.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric General Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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Leeuwenburgh MMN, Monpellier V, Vlaminckx BJM, Go PMNYH. Streptococcus milleri in intraabdominal abscesses in children after appendectomy: incidence and course. J Pediatr Surg 2012; 47:535-9. [PMID: 22424350 DOI: 10.1016/j.jpedsurg.2011.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 08/02/2011] [Accepted: 08/08/2011] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Intraabdominal abscesses are a common complication after appendectomy, especially in children. In this study, we describe the incidence and course of this complication in relation to the cultured pathogens found in intraabdominal abscesses. METHODS The charts of all patients between 1 and 18 years of age undergoing appendectomy in 3 hospitals between January 2006, and July 2009, were retrospectively reviewed. Presence of an intraabdominal abscess was confirmed with abdominal ultrasound examination. We collected all details concerning the appendectomy, pus cultures, and postoperative course in these patients. RESULTS Two hundred fifty-nine patients underwent appendectomy during the study period. Subsequently, abdominal ultrasound studies showed an intraabdominal abscess in 18 (7%) patients. Intraabdominal abscesses developed more frequently after perforated appendicitis (23%) than after simple appendicitis (2%). The incidence of postoperative abscesses did not differ significantly between open (5.6%) or laparoscopic (6.3%) appendectomy. However, the rate was high (38%) in the patients in whom the appendectomy was converted from laparoscopic to open. In 15 out of the 18 patients with a postoperative abscess drainage was performed. In pus cultures of the drained abscesses Streptococcus milleri and Escherichia coli were the most commonly isolated pathogens. Presence of S milleri was associated with prolonged hospital stay (13.9 versus 9.0 days, P = .105) and prolonged antibiotic treatment (11.3 versus 4.8 days, P = .203). CONCLUSIONS The incidence of intraabdominal abscesses is high after perforated appendicitis in children (23%). Our data suggest that the presence of S milleri correlates with a more complicated postoperative course after appendectomy in children.
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A double-blind study of the efficacy and safety of multiple daily doses of amikacin versus one daily dose for children with perforated appendicitis in Costa Rica. Int J Infect Dis 2011; 15:e569-75. [PMID: 21733727 DOI: 10.1016/j.ijid.2011.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 04/04/2011] [Accepted: 04/26/2011] [Indexed: 11/23/2022] Open
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Bacteriologic epidemiology and empirical treatment of pediatric complicated appendicitis. Diagn Microbiol Infect Dis 2011; 69:376-81. [PMID: 21396532 DOI: 10.1016/j.diagmicrobio.2010.11.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 11/04/2010] [Accepted: 11/06/2010] [Indexed: 01/09/2023]
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Chow AW, Evans GA, Nathens AB, Ball CG, Hansen G, Harding GKM, Kirkpatrick AW, Weiss K, Zhanel GG. Canadian practice guidelines for surgical intra-abdominal infections. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2010; 21:11-37. [PMID: 21358883 PMCID: PMC2852280 DOI: 10.1155/2010/580340] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Anthony W Chow
- Division of Infectious Disease, Department of Medicine, University of British Columbia and Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia
| | - Gerald A Evans
- Division of Infectious Diseases, Department of Medicine, Queen’s University, Kingston
| | - Avery B Nathens
- Department of Surgery, University of Toronto, Toronto, Ontario
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta
| | - Glen Hansen
- Departments of Pathology and Laboratory Medicine, University of Minnesota and Hennepin County Medical Center, Minnesota, USA
| | - Godfrey KM Harding
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
| | | | - Karl Weiss
- Department of Infectious Diseases and Microbiology, Hôspital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec
| | - George G Zhanel
- Department of Medical Microbiology and Medicine, University of Manitoba, Winnipeg, Manitoba
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Abstract
INTRODUCTION Antibiotics gained a place in the management of acute appendicitis when the bacterial aetiology was demonstrated. Culture swabs were obtained routinely during appendicectomies to guide antibiotic use. Although current antimicrobial therapy use has become prophylactic, empirical and broad spectrum, this age-old practice still remains. Our study questions the value of this traditional practice. MATERIALS AND METHODS All adult and paediatric patients undergoing emergency appendicectomy over three years were retrospectively reviewed. Microbiology and appendix histology reports were retrieved. Occurrence of infective post-operative morbidity was recorded via hospital notes. RESULTS A total of 652 appendectomies (age 1 month to 81 years, median 20 years) were performed in a 36 month period. Four hundred and thirty-five/six hundred and fifty-two (66.7%) had intra-operative swabs taken. One hundred and forty/four hundred and thirty-five (32%) revealed presence ofa pathogens. One hundred and twenty-two/four hundred and thirty-five (28%) were sensitive to broad spectrum empirical antibiotics and only 18/435 (4.1%) cultured resistant strains. Forty-two/six-hundred and fifty-two (6.4%) patients had postoperative infective complications. Twenty-nine/forty-two (68%) had a different organism responsible for this complication. The highest proportion of positive cultures and post-operative infective complications was observed in the extremes of ages (< 10 and > 50 years) and in gangrenous appendicitis. CONCLUSION A majority of intra-operative swabs were negative or isolated commensal flora. Pathogens causing postoperative morbidity were frequently different from those isolated intra-operatively. None of the patients had a change of management based on the swab results. Hence routine intra-peritoneal swabs remains of little clinical value.
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Affiliation(s)
- F J Foo
- Department of General Surgery, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Abstract
BACKGROUND To determine the impact of obtaining routine peritoneal fluid cultures during appendicectomy, on the treatment and the clinical outcomes. METHODS The case notes of 137 consecutive patients having appendicectomy, selected from the microbiology database over a period of 1 year were reviewed. The microorganisms in peritoneal cultures, selection of antibiotics and clinical outcomes were recorded. Patients were subdivided into two groups; group I: uncomplicated appendicitis and group II: complicated appendicitis. RESULTS The study included 137 patients with a median age of 19 years. Cultures were obtained from 79.5% of patients (group I: 67/84, group II: 42/53). Cultures were positive in 28.3% (19/67) patients in group I and 69% (29/ 42) in group II. Wound infection (5.6%), prolonged ileus (7.5%) and intra-abdominal abscess (3.7%) were the recorded complications in group II. Antibiotics were modified in 3 out of 109 patients. CONCLUSION Intra-operative peritoneal cultures during appendicectomy do not significantly contribute towards patient management.
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Affiliation(s)
- M N Khan
- Department of General Surgery, North Hampshire Hospital, Basingstoke, UK.
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Abstract
Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.
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Affiliation(s)
- Stephen E Morrow
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA.
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Coelho JCU, Baretta GAP, Okawa L. [Selection and use of anti-infective agents for intra-abdominal infections]. ARQUIVOS DE GASTROENTEROLOGIA 2007; 44:85-90. [PMID: 17639190 DOI: 10.1590/s0004-28032007000100018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Accepted: 07/03/2006] [Indexed: 05/16/2023]
Abstract
BACKGROUND Intra-abdominal infections are common and are associated with elevated morbidity and mortality. The microorganisms that cause intra-abdominal infections are usually from the gastrointestinal flora, mainly E. coli and Bacteroides fragilis. AIM To present a review of the selection and use of antibiotics in intra-abdominal infections. CONCLUSIONS Appropriate use of antibiotics is essential to control infection and to reduce treatment failure. Antibiotics are initiated whenever intra-abdominal infection is suspected and the antimicrobial agents are selected based on the most common microorganisms involved. In addition, efficacy, cost, safety, and posologic regimen are considered for an appropriated selection. Antibiotic regimen is different whether the infection is acquired in the community or at hospital due to the more resistant flora in the latter.
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Affiliation(s)
- Júlio Cezar Uili Coelho
- Serviço de Cirurgia do Aparelho Digestivo, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR.
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Moawad MR, Dasmohapatra S, Justin T, Keeling N. Value of intraoperative abdominal cavity culture in appendicectomy: a retrospective study. Int J Clin Pract 2006; 60:1588-90. [PMID: 17109667 DOI: 10.1111/j.1742-1241.2005.00774.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Appendicectomy is one of the most common surgical emergency procedures. Intraperitoneal culture during appendicectomy is routine practice in some hospitals, while some surgeons advocate abandoning this routine. The aim of our study is to determine the value of intraoperative abdominal cavity culture and its impact on the patient management. Retrospective analysis was performed on 498 patients who underwent appendicectomy over 2.5-year period. The median of the postoperative hospital stay was 2 days, while the median time taken to receive culture results was 3 days. A positive culture was found in 42.6%. Approximately 42.7% of the patients were discharged from the hospital before receiving the culture results. The culture and sensitivity results altered the antibiotic regimen in one patient (0.85%). Intraoperative abdominal cavity culture results were seldom used for clinical management in patients with acute appendicitis. The traditional surgical practice of routinely culturing peritoneal fluid in these patients should be abandoned.
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Affiliation(s)
- M R Moawad
- Department of Colorectal Surgery, West Suffolk Hospital, Cambridge University Teaching Hospitals Trust, Hardwick Lane, Bury St Edmunds, Suffolk IP33 2QZ, UK.
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Tan ECTH, Severijnen RSVM, Rosman C, van der Wilt GJ, van Goor H. Diagnosis and treatment of acute appendicitis in children: a survey among Dutch surgeons and comparison with evidence-based practice. World J Surg 2006; 30:512-8; discussion 519. [PMID: 16528461 DOI: 10.1007/s00268-005-0350-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Considerable variability exists in the surgical approach to acute appendicitis in children, affecting both quality and costs of care. A national survey provides insight into daily surgical practice and enables comparison of practice with the available evidence. METHODS A national survey was conducted in all 121 Dutch hospitals asking detailed information concerning diagnosis and treatment of children suspected of acute appendicitis. An evidence-based practice (EBP) score was developed on the basis of a critical appraisal of the literature, allowing for classification of reported practices with regard to the level of evidence and identification of hospitals working in accordance with the best available evidence. RESULTS The overall response rate was 93%. For the diagnosis of acute appendicitis, respondents relied predominantly on patient history (29%) and clinical examination (31%), followed by laboratory results (22%). Only 20% of the departments routinely measured total white blood cell count (WBC), C-reactive protein (CRP) and leukocyte differential count (proportion of polymorphonuclear cells), being part of the triad that provides diagnostic evidence. Although strong evidence exists in favour of routine prophylaxis for suspected appendicitis, only two thirds of surgical departments reported this as part of their routine practice. For a number of issues, reasonably consistent evidence is available (e.g. primarily versus delayed closure, drainage versus lavage, routine peritoneal culturing). Thirty-eight percent of the departments routinely cultured abdominal fluid despite various reports that it provides no therapeutic advantage. Not more than 22% of the departments closed the skin in perforated appendicitis in spite of clear supportive evidence. Considerable variation exists in cleaning the abdomen in perforated appendicitis, despite evidence favouring lavage. Comparing departments in terms of compliance with available evidence revealed that most paediatric surgery departments worked according to evidence-based medicine. CONCLUSIONS Available evidence on diagnosis and treatment of acute appendicitis in children is only partly applied in a small proportion of hospitals in the Netherlands. It is recommended that national guidelines be published, which could decrease health care costs and increase more uniform policy, improve quality of care for this group of patients and improve training of residents in general surgery in the Netherlands.
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Affiliation(s)
- E C T H Tan
- Department of General Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, P.O. Box 9101, 690, 6500, 6500 HB, The Netherlands.
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Mazuski JE, Sawyer RG, Nathens AB, DiPiro JT, Schein M, Kudsk KA, Yowler C. The Surgical Infection Society guidelines on antimicrobial therapy for intra-abdominal infections: evidence for the recommendations. Surg Infect (Larchmt) 2006; 3:175-233. [PMID: 12542923 DOI: 10.1089/109629602761624180] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Revised guidelines for the use of antimicrobial therapy in patients with intra-abdominal infections were recently developed by the Therapeutic Agents Committee of the Surgical Infection Society (Mazuski et al., Surg Infect 2002;3:161-173). These were based, insofar as possible, on evidence published over the past decade. The objective of this document is to describe the process by which the Committee identified and reviewed the published literature utilized to develop the recommendations and to summarize the results of those reviews. English-language articles published between 1990 and 2000 related to antimicrobial therapy for intra-abdominal infections were identified by a systematic MEDLINE search and an examination of references included in recent review articles. If current literature with regard to a specific issue was lacking, relevant articles published prior to 1990 were identified. All prospective randomized controlled trials, as well as other articles selected by the Committee, were evaluated individually and collectively. Data with regard to patient numbers, types of infections, and results of interventions were abstracted. Studies were categorized according to their design, and all included trials were graded according to quality. On the basis of this evidence, the Committee formulated recommendations for antimicrobial therapy for intra-abdominal infections and graded those recommendations. After receiving comments from invited reviewers and the general membership of the Society, the guidelines were finalized and submitted to the Council of the Surgical Infection Society for approval. The final recommendations related to the selection of patients needing therapeutic antimicrobials, acceptable antimicrobial regimens, duration of antimicrobial use, and the identification and treatment of higher-risk patients. Although numerous publications pertaining to these topics were identified, but nearly all of the prospective randomized controlled trials represented comparisons of different antimicrobial regimens for the treatment of intra-abdominal infections. A few prospective trials evaluated the need for therapeutic antimicrobial therapy in patients with peritoneal contamination following abdominal trauma. The quality of these prospective trials was highly variable. Many did not limit enrollment to patients with complicated intra-abdominal infections, lacked blinding of treatment assignment, did not provide a complete description of the criteria used to determine therapeutic success or failure, failed to identify the reasons why patients were excluded from analysis, or did not include an intention-to-treat analysis. For many issues, no prospective randomized controlled trials were encountered, and guidelines had to be formulated using evidence from studies with historical controls or uncontrolled data, or on the basis of expert opinion
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Affiliation(s)
- John E Mazuski
- Department of Surgery, Saint Louis University School of Medicine, St. Louis, MO 63110-1093, and Bronx Lebanon Hospital Center, Bronx, NY, USA.
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Vital Jr PF, Martins JL. Estado atual do diagnóstico e tratamento da apendicite aguda na criança: avaliação de 300 casos. Rev Col Bras Cir 2005. [DOI: 10.1590/s0100-69912005000600005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVOS: Avaliar o estado atual do diagnóstico e tratamento da apendicite aguda em crianças operadas em dois grandes hospitais quaternários da cidade de São Paulo, no período de 30 meses. MÉTODO: Nossa casuística constou de 300 crianças operadas por apendicite aguda no período de 1998 a 2000 (65% do sexo masculino e 35% feminino). Foram analisadas as variáveis idade, sexo, manifestações clínicas, tempo gasto para o diagnóstico, achados de exame físico, laboratoriais e cirúrgicos, antimicrobianos administrados, complicações pós-operatórias e tempo de internação. Utilizou-se o teste t de Student para avaliar duas variantes e Análise de Variâncias quando mais de duas. RESULTADOS: Diagnosticou-se inicialmente apendicite aguda em apenas 63% dos casos, tendo os 35% restantes, diagnóstico de abdome agudo cirúrgico. O tempo decorrido na realização do diagnóstico foi superior a 24 horas em 57,4% dos casos, denotando retardo importante na sua elaboração. Dor abdominal (85,3%) e irritação peritoneal (82%) em fossa ilíaca direita foram os sinais e sintomas mais freqüentes. Identificou-se leucocitose em 83% dos pacientes e leucocitúria em 39,7 %. Em 92,4% das radiografias simples de abdome encontramos imagens sugestivas de apendicite aguda. A ultra-sonografia abdominal foi diagnóstica em 80,1% dos casos. Utilizaram-se esquemas antimicrobianos especialmente para agentes gram-negativos e anaeróbicos. A principal complicação foi infecção da ferida cirúrgica, não tendo sido observada mortalidade no grupo. A média de internação foi de 5.2 e 6,0 dias para meninos e meninas respectivamente. CONCLUSÃO: Mesmo com melhor conhecimento sobre apendicite aguda, refinamento técnico, laboratorial, radiológico e uso de antibioticoterapia adequada, o tempo de para diagnóstico e a morbidade ainda se mantém alta na idade pediátrica.
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Mui LM, Ng CSH, Wong SKH, Lam YH, Fung TMK, Fok KL, Chung SSC, Ng EKW. Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis. ANZ J Surg 2005; 75:425-8. [PMID: 15943731 DOI: 10.1111/j.1445-2197.2005.03397.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The effect of extended prophylactic antibiotic therapy on postoperative infective complications such as wound infection and intra-abdominal abscess for non-perforated appendicitis is poorly defined. METHODS In a randomized controlled trial of 269 patients aged 15-70 years with non-perforated appendicitis undergoing open appendicectomy; 92 received single dose preoperative (group A), 94 received three-dose (group B) and 83 received 5-day perioperative (group C) regimens of cefuroxime and metronidazole. Postoperative infective complication was the primary endpoint. Secondary outcomes included length of hospital stay and complications related to antibiotic therapy. RESULTS The rate of postoperative infective complication was not significantly different among the groups (6.5% group A, 6.4% group B, 3.6% group C). The duration of antibiotic therapy had no significant effect on the length of hospital stay. Complications related to antibiotic treatment were significantly more common for 5-day perioperative antibiotic group (C) compared with single dose preoperative antibiotic group (A) (P = 0.048). CONCLUSION Single dose of preoperative antibiotics is adequate for prevention of postoperative infective complications in patients with non-perforated appendicitis undergoing open appendicectomy. Prolonging the use of antibiotics can lead to unnecessary antibiotic related complications.
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Affiliation(s)
- Lik Man Mui
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
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Snelling CMH, Poenaru D, Drover JW. Minimum postoperative antibiotic duration in advanced appendicitis in children: a review. Pediatr Surg Int 2004; 20:838-45. [PMID: 15480707 DOI: 10.1007/s00383-004-1280-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2004] [Indexed: 11/25/2022]
Abstract
The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated. A systematic review was performed, including published experimental and observational data of antibiotic use in children who had undergone appendectomy for advanced appendicitis. Data were extracted and analyzed according to predefined criteria. Twenty-eight studies were selected that included 2,284 patients. There was no consistency among the protocols regarding length of antibiotic use, discharge criteria, or use of home antibiotics following discharge. Limiting duration of antibiotic use to 3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection. In the absence of higher-level evidence, shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe.
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Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT, Buchman T, Dellinger EP, Jernigan J, Gorbach S, Chow AW, Bartlett J. Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections. Clin Infect Dis 2003; 37:997-1005. [PMID: 14523762 DOI: 10.1086/378702] [Citation(s) in RCA: 379] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Accepted: 06/30/2003] [Indexed: 02/02/2023] Open
Affiliation(s)
- Joseph S Solomkin
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA.
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Pelletier SJ, Raymond DP, Crabtree TD, Gleason TG, Pruett TL, Sawyer RG. Outcome analysis of intraabdominal infection with resistant gram-positive organisms. Surg Infect (Larchmt) 2003; 3:11-9. [PMID: 12593695 DOI: 10.1089/109629602753681113] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although the microbiology of intraabdominal infection has been well described, the role of resistant organisms remains unclear. To evaluate the hypothesis that intraabdominal infections from resistant gram-positive cocci (rGPC) have worse outcomes compared to those with susceptible organisms, patient characteristics and outcomes were compared between these groups. METHODS Analysis of peritoneal infections was performed on prospectively collected data of all consecutive surgical infections from December 1996 to June 1999 at a university hospital. Intraabdominal infection was defined either by a positive peritoneal cavity culture or on clinical grounds (e.g., abscess), which prompted antimicrobial or surgical therapy. Resistant Staphylococcus and Enterococcus spp. were defined as those strains resistant to oxacillin, gentamicin, or vancomycin. RESULTS Compared to episodes of intraabdominal infection from susceptible organisms (n = 365), infections due to rGPC (n = 52) were associated with an increased severity of illness (p < 0.0001), longer time from admission to treatment (p < 0.0001), longer duration of therapy (p = 0.008), greater proportion of nosocomial infection (p < 0.0001), increased length of stay (p < 0.0001), and an increased mortality rate (9% versus 23%; p = 0.003). However, comparison of intraabdominal infection with rGPC to a group controlled for severity of illness demonstrated a prolonged time from admission until treatment and longer duration of hospitalization but a similar mortality rate between groups (17% versus 23%; p = 0.46). CONCLUSION Intraabdominal infection with rGPC is an indicator of poor prognosis and severe illness. Although not an independent predictor of mortality, the significantly increased duration of therapy and prolonged duration of hospitalization may have considerable economic impact.
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Affiliation(s)
- Shawn J Pelletier
- Department of Surgery, Room 3150, MR4, Lane Road, University of Virginia Health Systems, Charlottesville, VA 22908, USA.
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Guzman D, Abramo TJ. Sorting out problems manifested by peritoneal irritation. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2002. [DOI: 10.1016/s1522-8401(02)90014-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rothrock SG, Pagane J. Acute appendicitis in children: emergency department diagnosis and management. Ann Emerg Med 2000; 36:39-51. [PMID: 10874234 DOI: 10.1067/mem.2000.105658] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Early diagnosis of appendicitis in infants and children can prevent perforation, abscess formation, and postoperative complications, and can decrease cost by shortening hospitalizations. This article reviews the epidemiology, physiology, and age-specific clinical presentation of childhood appendicitis. The accuracy of diagnostic adjuncts is reviewed, as are strategies for avoiding misdiagnosis and improving emergency department evaluation and management.
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Affiliation(s)
- S G Rothrock
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL 32806, USA
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Abstract
BACKGROUND The introduction of broad spectrum antibiotics has substantially decreased rates of mortality and morbidity associated with complicated appendicitis in children. The generally recommended therapy for children with complicated (gangrenous or perforated) appendicitis is administration of postoperative antibiotics for 3 to 14 days, but the decision as to the specific duration of treatment lies with the treating physician. AIM This study evaluates whether the recommendation that the combination of the patient's being afebrile and eating and having a normal white blood cell (WBC) count and < or = 3% band forms can be used to decide when sufficient antibiotics have been given and can be safely discontinued. METHODS Thirty-three consecutive patients seen in the pediatric surgical service with perforated or gangrenous appendicitis were studied prospectively. All patients received a standard protocol of resuscitation, appendectomy and broad spectrum antimicrobial therapy to be continued until they were eating, afebrile and had normal white blood cell counts with < or = 3% immature neutrophils (band forms). RESULTS Thirty-two children were treated until they met all criteria when antibiotics were stopped and the patients were discharged. Of these patients 31 had unremarkable courses of recovery with no development of intraabdominal abscess or wound infection [predictive value of criteria, 97% (31 of 32)]. The remaining patient who met the criteria required rehospitalization for treatment of intraabdominal abscess. Another patient was discharged prematurely when he failed to meet the criterion of afebrility. Although he was eating and his WBC count was normal, he had a temperature of 38.5 degrees C during the 24 h before discharge. He was readmitted for surgical drainage of an intraabdominal abscess, yielding a 100% predictive value for the criterion mismatch (1 of 1). CONCLUSION Based on our observations, when a patient with complicated appendicitis is afebrile for 24 h (temperature < 38 degrees C), is eating and has a WBC count with < or = 3% band forms, antibiotics can be safely discontinued with small risk of recurrent intraabdominal abscess.
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Affiliation(s)
- D J Hoelzer
- Department of Surgery, Christiana Care Health System, Wilmington, DE 19718, USA
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