Rational use of antibiotics for perforated appendicitis in childhood

Differences in isolated bacteria between perforated and non-perforated appendicitis: an analysis of 680 consecutive appendicectomies in a single institution

PURPOSE

Escherichia coli and Bacteroides species are the most frequently detected species in ascites in perforated appendicitis and are generally sensitive to non-empiric cephalosporins like cefazolin or cefmetazole. However, monotherapy with such antibiotics is mostly insufficient for perforated appendicitis. To investigate this issue, this study aimed to compare bacterial floras in ascites culture between perforated and non-perforated appendicitis.

METHODS

Ascites culture results in perforated and non-perforated appendicitis cases were analyzed using a departmental database. The duration of symptoms before surgery, pre-surgical white blood cell count, C-reactive protein value, postsurgical length of stay, length of antibiotic treatment, and the rate of using second-line antibiotics or complications were also compared.

RESULTS

A total of 608 and 72 cases of non-perforated and perforated appendicitis were included. Escherichia coli and Bacteroides species were the dominant bacteria in both conditions. However, the total proportions of Pseudomonas aeruginosa, Streptococcus anginosus group, and Enterococcus group were significantly higher in perforated appendicitis than in non-perforated appendicitis.

CONCLUSION

Pseudomonas aeruginosa, Streptococcus anginosus group, and Enterococcus group have better susceptibility to penicillin-based empiric antibiotics than cephalosporins. The abundance of these bacteria might explain why non-empiric cephalosporins are not effective in perforated appendicitis and the superiority of penicillin-based empiric antibiotics.

Quality metrics for emergency abdominal surgery in children: a systematic review

BACKGROUND

There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children.

METHODS

We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications.

RESULTS

We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways.

CONCLUSIONS

This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42017055285.

Optimal First-Line Antibiotic Treatment for Pediatric Complicated Appendicitis Based on Peritoneal Fluid Culture

PURPOSE

Consensus is lacking regarding the optimal antibiotic treatment for pediatric complicated appendicitis. This study determined the optimal first-line antibiotic treatment for pediatric patients with complicated appendicitis based on peritoneal fluid cultures.

METHODS

This retrospective study examined the cases of pediatric patients who underwent appendectomy for complicated appendicitis at our institution between 2013 and 2019. Peritoneal fluid specimens obtained during appendectomy were cultured for the presence of bacteria.

RESULTS

Eighty-six pediatric patients were diagnosed with complicated appendicitis. Of them, bacteria were identified in 54 peritoneal fluid samples. The major identified bacteria were Escherichia coli (n=36 [66.7%]), Bacteroides fragilis (n=28 [51.9%]), α-Streptococcus (n=25 [46.3%]), Pseudomonas aeruginosa (n=10 [18.5%]), Enterococcus avium (n=9 [16.7%]), γ-Streptococcus (n=9 [16.7%]), and Klebsiella oxytoca (n=6 [11.1%]). An antibiotic susceptibility analysis showed E. coli was inhibited by sulbactam/ampicillin in 43.8% of cases versus cefmetazole in 100% of cases. Tazobactam/piperacillin and meropenem inhibited the growth of 96.9-100% of the major identified bacteria. E. coli (100% vs. 84.6%) and P. aeruginosa (100% vs. 80.0%) were more susceptible to amikacin than gentamicin.

CONCLUSION

Tazobactam/piperacillin or meropenem is a reasonable first-line antibiotic treatment for pediatric complicated appendicitis. In the case of aminoglycoside use, amikacin is recommended.

Updates on bacterial resistance and empirical antibiotics treatment of complicated acute appendicitis in children

OBJECTIVE

Through historical comparison with our previous study published 10 years ago, this paper aims to provide latest analysis of local bacteriology of acute complicated appendicitis and evaluate the effects of early escalation of potent antibiotics on course of postoperative recovery.

METHODS

A 5-year retrospective review of all children receiving emergency laparoscopic appendicectomies for acute appendicitis from December 2014 to November 2019 was conducted.

RESULTS

257 cases of acute appendicitis were included, 126 were complicated appendicitis (38 gangrenous, 88 ruptured). 96 had positive peritoneal swab culture, 53 (42.1%) grew resistant bacterial strains, including extended spectrum beta-lactamase producing E. coli (ESBL E. coli), Pseudomonas aeruginosa, against traditional empirical triple antibiotics. The prevalence had significantly increased over the past decade (p = 0.008). In our patients, piperacillin/tazobactam, ertapenem, gentamicin provided coverage of 69.8%, 45.3% and 45.3% respectively. For patients with early escalation of postoperative antibiotics, no statistical significance was identified in terms of postoperative complications (p = 0.883), or duration of antibiotics (p = 0.0615).

CONCLUSION

Growing prevalence of resistant strains were observed over the decade. Piperacillin/tazobactam provided the best coverage (69.8%) against resistant bacterial strains in our patients. Early escalation of antibiotics failed to reduce postoperative complications and antibiotics duration.

TYPE OF STUDY

Clinical Research, Retrospective Historical Comparative Study Level of Evidence: Level III.

Delta neutrophil index and symptomatic time are effective factors for predicting perforated appendicitis

Appendicitis is a common intra-abdominal inflammatory disease, and morbidity increases with age when perforation occurs. Because, not all patients require emergency surgery, there have been numerous studies on factors for predicting perforated appendicitis. In this study, we aimed to confirm whether the delta neutrophil index (DNI) and the time from symptom onset to surgery are effective predictors for perforated appendicitis in different age groups.This was a retrospective study conducted on 542 appendicitis patients who underwent surgery at Kangdong Sacred Heart Hospital. The simple group consisted of 431 subjects, and the perforation group consisted of 111 subjects.Multiple logistic regression analyses demonstrated that age, neutrophil percentage, DNI, C-reactive protein (CRP), and symptomatic time were significant predictors of perforation. Analysis of the receiver-operating characteristic curve showed that the DNI was the most reliable predictive value. In the analyses according to age, the perforation rate was higher in the >65-year-age group; these patients also had a higher DNI, CRP, and symptomatic time. In the DNI analysis using receiver operating characteristic (ROC) analysis, the area under the curve was higher in the >65-year-age group than in other age groups. In addition, the cutoff values have been determined and perforation occurred significantly in the group with a DNI value of 2.1 or higher and a symptomatic time of 33 hours or longer.DNI is effective in predicting perforation in patients with appendicitis compared with other inflammatory factors. Furthermore, the simultaneous measurement of symptomatic time and DNI is helpful in predicting perforation and determining whether emergency surgery is necessary.

ANTIBIOTICS FOR APPENDICECTOMY IN CHILDREN AND ADOLESCENTS DURING THE PERIOPERATIVE PERIOD: AN INTEGRATIVE REVIEW

ABSTRACT Objective: To analyze the preoperative use of antibiotics in children and adolescents requiring appendectomy. Data source: Integrative review was performed in the MEDLINE, Latin American and Caribbean Health Sciences (LILACS) and Cochrane databases and the PubMed portal, with no time limit. The keywords used were: appendicitis, child, adolescent and antibacterial with Boolean AND. The articles included were published in Portuguese, English or Spanish and whose participants were under 18 years of age. Review articles and guidelines were excluded. The studies were classified according to their level of evidence and 24 papers were selected. Data collection and analysis: Seven randomized clinical trial studies (level of evidence II), eight cohorts (level III), seven retrospective observational studies (level V) and two historical documentary analysis (level IV) were selected. The studies addressed antibiotics used in acute appendicitis in both uncomplicated and complicated cases. Antibiotics initiated in the preoperative period showed a decrease in the rates of surgical wound infections. First-line (empiric) regimens were tested for sensitivity to microorganisms in peritoneal material cultures, however the results were controversial. Broad-spectrum antibiotics have been suggested in some studies because they have good coverage, but in others they have not been recommended because of the risk of developing bacterial resistance. Shorter administration time and earlier change to the oral route reduced hospitalization time. Conclusions: There are several clinical protocols with different antibiotics. However, there is no standardization concerning the type of antibiotic drug, time of use, or route.

Effects of Timing of Appendectomy on the Risks of Perforation and Postoperative Complications of Acute Appendicitis

BACKGROUND

It is generally believed that appendectomy should be performed immediately to prevent perforation and complications. Therefore, our objectives were to investigate the effect of timing of appendectomy on the incidence of perforation and complications.

METHODS

We retrospectively reviewed the medical records of patients who underwent laparoscopic appendectomy between January 2014 and June 2015. The time from symptom onset to appendectomy was categorized into three periods: time from symptom onset to hospital admission (symptomatic time), time from admission to appendectomy (hospitalization time), and time from symptom onset to appendectomy [symptomatic period + hospitalization period (overall time)]. Multivariable analyses were performed to identify independent factors associated with perforation and complications.

RESULTS

A total of 1753 patients were included in the present study. Perforation occurred in 28.2% of patients, and postoperative complications occurred in 10.0% of patients. Multivariable analysis showed that BT > 38 °C (P = 0.006), WBC count >13,000 cells/µl (P = 0.02), neutrophil ratio >80% (P < 0.001), and symptomatic time >24 h (P < 0.001) were independent factors of appendiceal perforation, while the neutrophil ratio >80% (P < 0.001) and symptomatic time >48 h (P = 0.003) were independently associated with complications.

CONCLUSIONS

The present study showed that the symptomatic time and overall time were significantly associated with perforation and complications, whereas hospitalization time was not associated with either perforation or complications.

Drainage vs no drainage in secondary peritonitis with sepsis following complicated appendicitis in adults in the modern era of antibiotics

AIM

To compare the profile of postoperative outcome in secondary peritonitis with sepsis due to complicated appendicitis in two cohorts (drainage vs no-drainage) after appendicectomy in adults in the modern era of effective antibiotics.

METHODS

A retrospective review of all adult patients who were operated for secondary peritonitis with sepsis due to complicated appendicitis was carried out. Total of 209 patients were identified from May 2005 to April 2009 with operative findings of gangrenous or perforated appendix. The patients were divided into two cohorts, those where prophylactic drainage was established (n = 88) and those where no drain was used (n = 121). Abdominal drain was removed once the drainage ceased or decreased (< 10-20 mL/d in closed system of drainage or when once daily dressing was minimally soaked in open system). Broad spectrum antibiotics to cover the gut flora were started in both cohorts at diagnosis and were stopped once septic features resolved. Peritoneal fluid for aerobic culture and sensitivity were routinely obtained intra operatively; however antibiotic regimens were not changed unless patient failed to respond to the antibiotics based on the institutional protocol. The co-morbidities and their influence on primary end points were noted. Immunocompromised patients, appendicitis complicated by inflammatory bowel disorder and tumors were excluded from the study.

RESULTS

Disease stratification and other demographic features were comparable in both cohorts. There was zero mortality in drainage group while as one patient (0.82%) died in the non-drainage group. The median duration (in days) of hospital stay (6.5 vs 4); antibiotic use (5 vs 3.5); regular parental analgesic use (5 vs 3.5) and paralytic ileus (2.5 vs 2) was more common in the drainage group. Incidence of major wound infection in patients 14 (15.9%) vs 22 (18.18%) and residual intra-abdominal sepsis (inter loop collection/abscess) -7 (8%) vs 13 (10.74%) requiring secondary intervention was not significantly different in drainage and non-drainage cohorts respectively. One patient in the drainage cohort had faecal fistula (1.1%).

CONCLUSION

The complicated appendicitis in the modern era of antibiotics does not necessitate the use of prophylactic drain placement which at times may even prove counterproductive.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prompt or delayed appendectomy? Influence of timing of surgery for acute appendicitis

PURPOSE

The aim of the study was to compare the clinical outcomes and histological findings in prompt and delayed appendectomy for acute appendicitis.

METHODS

All patients who underwent appendectomy for histologically confirmed acute appendicitis from 2003 to 2009 were included in this study. Patients were divided into three groups according to the time of surgery after hospital admission: The early appendectomy (EA) group underwent surgery within 12 h, the early-delayed appendectomy (EDA) group between 12 and 24 h and the delayed appendectomy (DA) group more than 24 h. The perioperative data and pathological state of the appendix were evaluated and compared.

RESULTS

A total of 723 patients, with histologically confirmed acute appendicitis, were included in the study: There were 518 patients in the EA group, 140 patients in the EDA group and 65 patients in the DA group. The operative times were similar in each group. Postoperative complications occurred in 49 patients (6.8 %) and were significantly higher in the DA group in comparison to the EA group (p = 0.0012) and EDA group (p = 0.003). Two patients (3 %) in the DA group died. There were no differences in the length of the hospital stay. The gangrenous appendicitis rate was significantly higher in the DA group (p < 0.05) in comparison to the EA and EDA groups.

CONCLUSIONS

Performing appendectomy within 24 h from presentation does not increase the length of hospital stay or rate of complications. However, delayed appendectomy after 24 h from onset increases the rate of complications.

Streptococcus milleri in intraabdominal abscesses in children after appendectomy: incidence and course

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.

Peritoneal fluid culture in appendicitis: review in changing times

Appendicectomy is one of the commoner operations with a lifetime risk as high as 12% or 23% in males or females, respectively. Since the 1940s intra-operative intra-peritoneal swabs have commonly been taken from the appendix site, the spectrum of infecting organisms and their antibiotic sensitivity may be gauged from the culture results. This approach remains common but in recent years, studies have claimed that intra-peritoneal swabs are unnecessary; however, they relied upon retrospective patient groups predating wider use of laparoscopic appendicectomy, increasing numbers of immunocompromised people at risk of appendicitis and the clinical/medicolegal significance of increasing risk of antibiotic-associated Clostridium difficile colitis. Therefore, a key-word literature research was done to identify relevant publications from 1930 to June 2009. Newer features relating to intra-peritoneal swabs in appendicectomy have been discussed against this background information for periabdominal appendicectomy with or without appendicular perforation, laparoscopic appendicectomy and appendicectomy in the growing numbers of immunocompromised patients. All studies questioning the use of intra-peritoneal swabs were open, non-randomised, and retrospective with incompletely matched control groups, non-standardised swab collection techniques, and consequently lacked power to inform surgical practice. They concluded that an appropriately powered randomised, blinded, prospective, controlled clinical trial is needed to test for absolute efficacy in the use of peritoneal swabs in patient management. Until controlled trial data becomes available, it may be wise to continue peritoneal swabs at least in high-risk patients to decrease clinical and medicolegal risk.

Intra-operative culture swabs in acute appendicitis: a waste of resources

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.

Is there a role for routine abdominal imaging in predicting postoperative intraabdominal abscess formation after appendectomy for pediatric ruptured appendix?

To determine if there is a role for routine abdominal imaging in predicting postoperative intraabdominal abscess after appendectomy for the pediatric ruptured appendix. From January 2000 to December 2003 inclusive, 44 consecutive pediatric patients with a ruptured appendix had an open appendectomy and were treated for a minimum of 5 days with triple antibiotics. On postoperative day 5, each patient was evaluated for symptoms (fever, abdominal pain, gastrointestinal dysfunction) and radiological evidence of an intraabdominal fluid collection. Further treatment was determined by the clinical evidence of continuing infection. On postoperative day 5, 36 (82%) of the 44 patients were asymptomatic, had an intraabdominal fluid collection less than 5 cm, diagnosed by ultrasound or computed tomography and received no further treatment. Two of these 36 patients (6%) returned within a week, symptomatic and with a larger collection suspicious for an intraabdominal abscess and requiring further treatment. The other 8 (18%) were symptomatic, and had an intraabdominal abscess more than 5 cm on imaging. All required further treatment, and recovered well. The use of routine abdominal imaging on postoperative day 5, (compared with clinical evaluation), did not improve the ability to predict the development of an intraabdominal abscess.

Does noncomplicated acute appendicitis cause bacterial translocation?

It is unknown whether noncomplicated acute appendicitis cause bacterial translocation. In this study, we aimed to test development of the bacterial translocation in the patients who were operated for acute appendicitis. In this prospective study, 10 control patients who underwent elective operations because of other reasons, and 18 patients with noncomplicated acute appendicitis were evaluated. No patients took prophylactic antibiotic. After laparotomy, samples were obtained from peritoneal leaf just close to wound edge, and peritoneal swab culture from right paracolic region. Before appendectomy, a mesenteric lymph node (MLN) adjacent to the terminal ileum was taken out. Tissue samples were placed in a sterile container for microbiological analysis, and 10% formalin for histopathological analysis. Control samples had no bacterial translocation. Only 3 of 18 (16.6%) patients with appendicitis included bacterial translocation to MLN. There was no significant difference between both groups. No bacterial colonization was detected in the peritoneal tissue and peritoneal swab culture. Peritoneal tissue injury score was 2 +/- 1.4 in controls and 2.8 +/- 1.7 in the patients with appendicitis (P>0.05). MLN injury score was 2.5 +/- 1.3 in controls and 3.2 +/- 1.5 in the patients with appendicitis (P>0.05). No patient developed wound and systemic infection. No significant bacterial translocation frequency and tissue injury score was identified in the children with noncomplicated acute appendicitis. This result suggests that antibiotic prophylaxis may be unnecessary in such patients.

Aminoglycoside-based triple-antibiotic therapy versus monotherapy for children with ruptured appendicitis

OBJECTIVE

We conducted a retrospective cohort study to compare the use of triple therapy versus monotherapy for children and adolescents with perforated appendicitis and to determine whether there has been a transition to monotherapy within the freestanding children's hospitals that contribute to the Pediatric Health Information System database.

METHODS

We used the Pediatric Health Information System database, which includes billing and discharge data for 32 children's hospitals in the United States, to examine the trend in antibiotic usage and whether the postappendectomy antibiotic regimen was associated with differences in complication-related readmissions, length of stay, or charges in a population of children and adolescents with ruptured appendicitis and discharge dates between March 1, 1999, and September 30, 2004. Pairwise regression analyses were performed to compare the most common monotherapy regimens with the triple therapy.

RESULTS

A total of 8545 patients met the inclusion criteria, of whom 58%, over the entire study period, received the aminoglycoside-based triple antibiotic therapy on postoperative day 1. There was, however, a notable transition over this 6-year period, from 69% to 52% of surgeons using aminoglycoside-based combination therapy. There were no significant differences in the odds of readmission at 30 days except for the group receiving ceftriaxone, which was associated with significantly decreased odds. The subgroup receiving piperacillin/tazobactam monotherapy demonstrated significantly decreased length of stay (-0.90 days) and total hospital charges, and the group receiving cefoxitin demonstrated significantly decreased length of stay (-1.89 days), as well as decreased pharmacy and total hospital charges.

CONCLUSIONS

Single-agent antibiotic therapy in the treatment of perforated appendicitis is being used with increasing frequency, is at least equal in efficacy to the traditional aminoglycoside-based combination therapy, and may offer improvements in terms of length of stay, pharmacy charges, and hospital charges.

Current management of appendicitis

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.

Appendicitis in the child with a ventriculo-peritoneal shunt: a 30-year review

PURPOSE

Each year, about 270 children are treated at our hospital for appendicitis, and there are 200 ventriculo-peritoneal (VP) shunt procedures. The incidence of primary peritonitis after a VP shunt is 8% to 12%. The purpose of this article is to try and differentiate these 2 entities.

METHODS

From 1973 to 2003 inclusive, appendicitis was diagnosed in 8 children with a VP shunt at our hospital; there were 7 boys and 1 girl with 5 acute appendicitis and 3 ruptured appendices. The first case was diagnosed on purely clinical grounds, whereas the last 7 were confirmed by ultrasonography and/or computed tomography.

RESULTS

All 8 had appendectomy and the shunt was exteriorized in the 3 children with a ruptured appendix. There were no postoperative problems, and the 8 children remained well.

CONCLUSION

Acute appendicitis can and does rarely occur in children with VP shunts; however, in such situations, the correct diagnosis can be confirmed by imaging. The shunt must be temporarily exteriorized if the appendix is ruptured.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis

AIM OF STUDY

The aim of this study was to determine if the presence of an appendicolith is associated with an increased risk for recurrent appendicitis after nonoperative treatment of pediatric ruptured appendix with inflammatory mass or abscess.

METHODS

Ninety-six pediatric patients (52 girls, 44 boys), aged 16 months to 17 years (average, 7 years), were managed between 1980 and 2003. All were treated nonoperatively with intravenous triple antibiotics for 5 to 21 days. All children had at least a 2-year follow-up. This study was approved by the hospital research ethics board.

MAIN RESULTS

Six children (6%) who became worse and 41 (46%) who had an interval appendectomy were eliminated from the study. The other 49 patients comprised the study group and received no further treatment. Twenty-eight (57%) had no recurrence, and 21 (43%) had a recurrence within 1 month to 2 years (average, 3 months). In the study group, 31 (63%) children had no appendicolith on radiological imaging and 18 (37%) had. Presence of an appendicolith was associated with a 72% rate of recurrent appendicitis compared with a recurrence rate of 26% in those with no appendicolith (chi2 test, P < .004).

CONCLUSION

We conclude that the patients with appendicolith should have an interval appendectomy.

Primary versus delayed wound closure in complicated appendicitis: an international systematic review and meta-analysis

The purpose of this study was to determine, by means of a systematic review, whether the method of wound closure in complicated appendicitis affects the incidence of wound infection. A comprehensive literature search of multiple databases including MEDLINE (1980-2003), was performed, using the Cochrane search strategy, for articles on wound closure and complicated appendicitis. Clinical trials examining the method of wound closure were selected for systematic review and all quasi-randomized and randomized trials underwent meta-analysis. Failure to close the wound as planned in delayed closure (DC) was considered indicative of a wound infection. Purulent drainage requiring wound opening indicated an infection in the wounds closed primarily. Six randomized trials were considered adequate for meta-analysis. None independently showed a statistically significant difference in the risk of developing a wound infection with primary closure (PC). When pooled data were subjected to meta-analysis, PC achieved a statistically significant reduction in the relative risk of treatment failure and did not lead to an increase in wound infections. Primary closure does not increase the risk of developing a wound infection after operation for perforated appendicitis. Given the lack of benefit of DC, and the less traumatic, less painful, and less costly nature of PC; primary closure is a safe and practical treatment option.

Minimum postoperative antibiotic duration in advanced appendicitis in children: a review

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.

The Efficacy of Postoperative Oral Antibiotics in Appendicitis: A Randomized Prospective Double-Blinded Study

The conventional treatment of acute appendicitis is appendectomy followed by intravenous (IV) antibiotics until intraabdominal infection has resolved. It is controversial as to whether it is efficacious to add a course of oral antibiotics after cessation of IV antibiotics. All consenting patients who presented to Kern Medical Center between October 2000 and June 2003 with acute appendicitis were entered into the study. Perforated/gangrenous appendicitis was equally represented in the two study arms. After appendectomy, and when IV antibiotics were ready to be discontinued, patients were randomized to receive a 7-day outpatient course of either placebo (Group 1) or oral antibiotics (Group 2). Patients were monitored for infectious complications for a minimum of 3 months, and there was no statistical difference (11.5% in Group 1 vs 12.1% in Group 2, P = 0.61). The data suggest that adding a course of outpatient oral antibiotics, after completing a course of IV antibiotics, does not decrease postoperative infectious complications in appendicitis patients.

Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis

BACKGROUND

Children with a perforated or gangrenous appendix become clinically stable after medical and/or surgical therapy but often remain in the hospital solely to complete parenteral antibiotic therapy. This prospective study investigates the outcomes when children who meet specified criteria are discharged to complete parenteral antibiotic therapy at home.

METHODS

Children age 1 to 17 years with appendicitis complicated by generalized peritonitis or intraabdominal abscess were eligible to participate. Subjects whose fever was decreasing, who were able to tolerate oral liquids and for whom further parenteral antibiotic therapy was deemed necessary were discharged from the hospital to receive outpatient parenteral antiinfective therapy (OPAT) with meropenem. Therapy was administered by a family member and supervised by home care nurses. Study personnel visited the home daily to collect data on adverse events, compliance and resource utilization. Pa tients served as their own controls in models of reduced hospitalization and net cost savings.

RESULTS

Discharged on average on the fourth postoperative day, 87 children received 4.5 +/- 2.1 days of OPAT. Six (7%) children were subsequently readmitted for complications including bowel obstruction (4 children), intraabdominal abscess (1 child) and pleural effusion (1 child). Another child developed a viral syndrome during OPAT. All other patients recovered uneventfully. Six (7%) children discontinued meropenem prematurely because of rash (4 patients) or diarrhea (2 patients). According to models in which each day of OPAT replaced a day of inpatient care, discharge to OPAT reduced hospitalization by 42 +/- 15% and saved a median of $2908 (10th to 90th percentile range, $1,077 to $4,707) per patient.

CONCLUSION

Convalescent phase OPAT is a cost-effective alternative to continued hospitalization for children with complicated appendicitis who are clinically stable yet require further parenteral antibiotic therapy.

Complicated Appendicitis: Is There a Minimum Intravenous Antibiotic Requirement? A Prospective Randomized Trial

The proper duration of postoperative intravenous (IV) antibiotics in patients suffering complicated (perforated or gangrenous) appendicitis is debatable. Some advocate a set minimum number of IV antibiotic days whereas others discontinue IV antibiotics depending on the patient's clinical course regardless of the length of therapy. Our objective was to determine whether there are differences in morbidity and resource utilization between the two treatment methodologies. Ninety-four patients with intraoperative findings of complicated appendicitis were included. In all patients IV antibiotics were discontinued on the basis of clinical factors. However, Group 1 patients were given a minimum 5-day IV antibiotic course whereas Group 2 patients had no minimum IV antibiotic requirement. Group 1 patients received more IV antibiotics than Group 2 patients did (5.9 vs 4.3 days; P = 0.014). Infectious complications were not statistically different between the two groups (13.0% in Group 1 and 12.5% in Group 2). Average hospital stay was also not statistically different between the two groups. The data suggest that a protocol with no minimum IV antibiotic requirement in patients with complicated appendicitis does not increase morbidity. Furthermore, the protocol arm with no minimum IV antibiotic requirement led to less IV antibiotic use but did not significantly decrease hospital stay.

Determining duration of antibiotic use in children with complicated appendicitis

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.

Can Oral Metronidazole Substitute Parenteral Drug Therapy in Acute Appendicitis?: A New Policy in the Management of Simple or Complicated Appendicitis with Localized Peritonitis: A Randomized Controlled Clinical Trial

To demonstrate the efficacy of oral metronidazole (OM) in simple or complicated appendicitis with localized peritonitis, a randomized prospective study was carried out in 1083 patients, ranging in age from 4 to 50 years (mean age, 21.38).

The patients were randomly divided into two groups. The study group (SG) (524 patients) received OM (500 mg for adults, 7–10 mg/kg if less than 15 years) 2–3 hours before operation. The drug was continued 4 to 5 hours after operation, every 8 hours, for three doses if the appendix was mild to severely inflamed. In the case of complicated appendicitis (114 patients), the same dose was given for 3 to 6 days, depending on the absence or presence of pus. Ceftizoxime was administered to the control group (CG) (559 patients) 2 to 3 hours before operation and then postoperatively every 6 hours for three doses if the appendix was mild to severely inflamed. The complicated cases in the CG (120 patients) received a combination of penicillin, chloramphenicol, and gentamicin for 3 to 6 days, depending on the absence or presence of pus.

The serum concentration of metronidazole measured in 43 patients was at bactericidal level in 40 (mean ± SD standard deviation, 10.65 ± 4.89 μg/mL).

The rate of wound infection was not significantly different in the SG and the CG with the same degree of pathology (3.17% vs 2.96% if uncomplicated; 15.78% vs 14.16% if complicated, respectively). Pelvic collection occurred in four adults and one child in the CG with perforated appendicitis (4.16%). The same complication developed in two adults and two children in the SG with perforated appendicitis (3.5%). All six adults and one of the children in the SG had to be re-explored, whereas the remaining two children responded to conservative management (OM and gentamicin). In uncomplicated cases, hospital stay and hospital charge were both almost the same in both groups. However, length of hospitalization was nearly 1 day shorter and hospital cost per day was about 30 per cent less in complicated cases in the SG as compared with the CG.

Conclusively, OM may not only substitute parenteral antibiotics in acute appendicitis as a prophylactic agent, but it may also be used as a cost-effective drug and is more convenient to the patient.

Abscess after appendicectomy in children: the role of conservative management

BACKGROUND

Intra-abdominal abscess remains a significant cause of morbidity following appendicectomy. In children, little emphasis has been placed on the non-invasive management of this complication using antibiotic therapy alone. This study reviews the experience of a paediatric surgical department in managing abscess arising after appendicectomy.

METHODS

Hospital records of all children undergoing appendicectomy between January 1992 and January 1997 were reviewed retrospectively.

RESULTS

Some 1024 children underwent appendicectomy over a 5-year period. Twenty three patients (2.2 per cent) developed abscesses after appendicectomy. Non-operative management with intravenous or oral antibiotics alone was successful in 21 patients, with complete clinical and radiological resolution of the abscess. Drainage of the septic collection was performed in only two patients: by laparotomy (n=1) and by the transrectal route (n=1).

CONCLUSION

Antibiotic therapy alone is an efficacious and safe first-line treatment modality in children who develop this complication. Drainage of an abscess developing after appendicectomy is rarely necessary in children.

Is abdominal cavity culture of any value in appendicitis?

BACKGROUND

Intraperitoneal culturing during appendectomy is a routine procedure. Significant decrease in the mortality and dramatic improvement in the morbidity were achieved by using antibiotics perioperatively. The value of intraoperative abdominal cavity culture was assessed in our study.

METHODS

A total of 499 patients formed two groups, those with acute nonperforated appendicitis (group A) and those with perforated appendicitis (group B). Intraoperative abdominal cavity culture were taken randomly in both groups. The perioperative morbidity, the validity, and the impact of positive culture on the antibiotic treatment were examined in both groups.

RESULTS

Clinical diagnosed perforation was confirmed histologically in 176 patients (98.3% accuracy). Intraperitoneal cultures were obtained in 30.1% of the patients in group A and in 67.1% of group B. The majority of the patients in group A were treated preoperatively and postoperatively by a single antibiotic agent whereas 58.0% of the patients in group B were started on triple-agent antibiotics for significantly longer periods (22.4 +/- 9.4 versus 5.7 +/- 7.4 doses, respectively; P < 0.0001). No significant difference was found in both groups in the postoperative complication rate (wound infection, intra-abdominal abscess and small bowel obstruction) whether intra-abdominal culture was obtained or not (5.9% versus 4.7% in group A and 21.2% versus 21.9% in group B; P > 0.05).

CONCLUSION

Traditional intraoperative abdominal cavity culture can be abandoned. In perforated appendicitis, colonic flora can be predicted, and antibiotic therapy should begun without any abdominal cavity culture results. This practical approach will save money and reduce laboratory work without affecting the patient's morbidity.

Preoperative administration of antibiotics in patients with suspected acute appendicitis

The effectiveness of administering antibiotics preoperatively to patients with suspected appendicitis was evaluated over a 2-year period in 105 consecutive patients who presented with right lower quadrant (RLQ) tenderness and a white blood cell (WBC) count of over 10,000/mm3 or a temperature of over 37 degrees C. All the patients were preoperatively administered cefazolin (CEZ), cefotiam (CTM), or fosfomycin (FOM) except those with apparent peritonitis, which resulted in the recovery of 41 patients (39%). Of the remaining 64 patients, 14 (13%) had catarrhal appendicitis, 34 (32%), phlegmonous appendicitis, and 16 (15%), gangrenous appendicitis. Preoperatively, there were no significant differences among these groups in the WBC count or temperature. Following the administration of antibiotics, both these parameters decreased significantly in the patients with catarrhal appendicitis, although a slight RLQ tenderness persisted; in those with phlegmonous appendicitis, the WBC count decreased significantly, but the temperature remained elevated, with slight rebound tenderness in the RLQ; and in those with gangrenous appendicitis, there were no significant differences between the pre- and postoperative data in WBC count or temperature, and the abdominal symptoms did not change. These results show the value of administering antibiotics within 24h of the onset of symptoms indicative of acute appendicitis to allow time to evaluate the patients' condition, decide the operative indications, and prevent unnecessary laparotomy.

Peritoneal lavage versus drainage for perforated appendicitis in children

A total of 231 children with acute appendicitis were treated at our hospitals during the 10 years between 1984 and 1993, 53 of whom had a perforated appendix. These 53 patients were randomly assigned to two groups at the time of surgery according to the different procedures performed. Thus, 29 children were managed by appendectomy followed by peritoneal lavage using a large amount of saline, and intravenous antibiotic therapy consisting of aminoglycoside and cephem (lavage group), while the other 24 children were treated by appendectomy with silicon tube drainage and the same systemic antibiotic therapy (drainage group). The mean length of hospitalization, and the mean durations of fever and the need for fasting after laparotomy in the lavage group were significantly less than those in the drainage group: 10.1 versus 18.8 days, 2.8 versus 7.7 days, and 1.8 versus 3.5 days, respectively. The operation wounds healed well in the lavage group due to the fact that there was no drain. Wound infections occurred in two children from the lavage group and six from the drainage group. Intra-abdominal abscesses occurred in two children from the drainage group. Accordingly, peritoneal lavage appears to be superior to intraperitoneal tube drainage for the management of perforated appendicitis in children.

Pediatric appendectomy

PURPOSE

To define patterns of care and outcome for pediatric appendectomy.

METHODS

A study was designed to evaluate all pediatric appendectomies performed in the 147 Department of Defense hospitals worldwide. Cases of nonincidental appendectomy were identified through discharge diagnoses and operative logs, and 98.6% of the charts were retrieved for review. All charts were abstracted, and data were entered into a 127-field database for analysis.

RESULTS

Over a 12-month period, ending January 1993, appendectomy was performed on 1,366 pediatric patients in the Department of Defense hospital system. The patients' median age was 12 years (range, 6 months to 18 years); 59% were male. The diagnosis was normal appendix for 157 patients (12%), acute nonperforated appendicitis for 930 (68%), and perforated appendicitis for 279 (20%). Age < or = 8 years was predictive (P < .001) of a higher rate of perforated appendicitis (33% v 18%) but was not predictive of normal pathology (13% v 11%). Female gender was associated with a significantly higher rate of normal pathology (17% v 8%; P < .001) but not of perforation (18% v 22%). Temperature elevation and right lower quadrant pain and tenderness did not clinically distinguish between diagnostic groups. Sixty-two percent of patients with a normal appendix had a white blood cell count of more than 10,000/mm3, as did 91% of patients with acute or perforated appendicitis. Those with perforated appendicitis received pre- and postoperative antibiotics, primarily ampicillin/gentamicin/clindamycin or Flagyl (41%), cefoxitin (34%), or Unasyn (15%). In 77% of this subgroup, intraoperative cultures were positive, with isolates for Escherichia coli (76%) Enterococcus (30%), Bacteroides (24%), and Pseudomonas (20%) predominating. There were no deaths. Major complications occurred in 1.2% of patients with acute appendicitis and in 6.4% of those with perforated appendicitis; there were no major complications in the group with normal appendectomies. The hospitalization period was more than 7 days for 1.6%, 40%, and 3.8%, respectively.

CONCLUSION

This large series, from a large number of hospitals, with multiple practitioners, can serve as a community standard for pediatric appendectomy in the 1990s.

Management of perforated appendicitis in children: a decade of aggressive treatment

Perforated appendicitis in children continues to be associated with significant morbidity. In 1976, a treatment algorithm was begun at the authors' institution, which included immediate appendectomy, antibiotic irrigation of the peritoneal cavity, transperitoneal drainage through the wound, and 10-day treatment with intravenous ampicillin, clindamycin, and gentamicin. Initial results with this scheme in 143 patients demonstrated a 7.7% incidence of major complications and no deaths. From 1981 through 1991, the authors continued to use this treatment plan in all patients with perforated appendicitis. Three hundred seventy-three patients with perforated appendicitis were treated, and the rate of major complications was 6.4%. Infectious complications occurred in 18 patients (4.8%) and included intraabdominal abscesses (5 patients, 1.3%), phlegmon treated with an extended course of antibiotics (6 patients, 1.6%), wound infections (5 patients, 1.3%), and enterocutaneous fistula requiring further operations (2 patients, 0.5%). There were six cases of small bowel obstruction (1.6%), which required operative intervention. There were no deaths. The average length of stay for all patients was 11.4 days (range, 8 to 66 days). Utilization of transperitoneal drainage and choice of antibiotic therapy continue to be sources of controversy in the surgical literature. However, the treatment plan used in the present study resulted in the lowest complication rate reported to date, and the authors conclude that this scheme is truly the "gold standard" for treatment of perforated appendicitis. New treatment plans using laparoscopic appendectomy, different or shorter courses of antibiotics, or not using drains should have complication rates that are as low as, or lower than this one to be considered as useful alternatives.

Peritoneal cultures and antibiotic therapy in pediatric perforated appendicitis

We retrospectively reviewed 70 cases of perforated appendicitis in children to examine the relationship between postoperative antibiotic selection and culture results from the peritoneal cavity. Initial antibiotic therapy chosen for the children consisted of a three-drug combination in 54 (77%) patients. Peritoneal cultures were performed in 58 (83%) patients. Escherichia coli and Bacteriodes fragilis were the most common bacterial isolates from the peritoneal culture. Only 7 (10%) patients had their antibiotic regimen changed after the culture results were available, of which 2 changes brought drug therapy into compliance with the cultures and 5 changes were inappropriate with respect to the peritoneal cultures. Of the remaining 51 patients with culture data available, 39 should have had changes to bring the antibiotic therapy into compliance with the observed culture results. These data indicate that surgeons select antibiotic therapy for perforated appendicitis in children based on assumptions of which organisms should be present in the infection and not on culture data. There appears to be no clinical usefulness to the routine culturing of the peritoneal cavity in children with perforated appendicitis.

Does the current health care environment contribute to increased morbidity and mortality of acute appendicitis in children?

To determine whether the current "gatekeeper" controls on health care lead to an increase in treatment delay and morbidity of acute appendicitis in children, we reviewed the experience with this disease at a large children's hospital over a 10-year period. One hundred seven consecutive children 18 years and younger operated on for acute appendicitis from July 1, 1988 to June 30, 1990 were compared with 119 children with the same diagnosis from July 1, 1978 to June 30, 1980. Age, sex, race, antecedent illnesses, initial physician contact and diagnosis, time to referral and operation, pathology, morbidity, and length of stay were reviewed. The two groups were comparable in terms of age, sex, race, antecedent illnesses, and negative appendectomy rate. More patients in the recent group were initially seen in an emergency room or urgent care setting than in the previous group (62.2% v 48.5%, P = .07). The accuracy of the initial diagnosis was significantly lower in the more recent group (P = .05). No change existed between the groups in the time to a physician; however, a significant (P = .04) difference existed in the time to surgeon (41.2 hours in the earlier group v 56.4 hours in the recent group). No significant difference existed between the groups in time from surgeon to operation. Although not statistically significant, the morbidity rate was increased in the recent group (13.3% v 6.5%, P = .17).(ABSTRACT TRUNCATED AT 250 WORDS)

The treatment of complicated appendicitis in children using peritoneal drainage: results from a public hospital

During the 2-year period from January 1, 1987 to December 31, 1988, 656 emergency appendectomies were performed on the Pediatric Surgery Service at the Los Angeles County-USC Medical Center. Of these, 398 patients were 12 years of age or less, and 227 appendices (57%) were perforated or gangrenous. The records of 167 of those patients with perforated or gangrenous appendices, treated by a standardized protocol are summarized. The protocol included perioperative antibiotics of gentamicin and clindamycin, appendectomy through a muscle-splitting incision, irrigation of the peritoneal cavity with saline, and peritoneal drainage through the lateral aspect of the wound with skin closure. There was no mortality, and the major complication rate was 8%, with 3% developing intraabdominal abscesses and 5% with bowel obstructions. The minor complication rate was 11%, and included prolonged ileus and prolonged fever, with no wound infections. The average hospital stay was 8.7 days. Our experience suggests that the adopted protocol is reliable for preventing wound infections without increasing the rate of intraabdominal abscesses in an innercity population with particularly advanced stages of appendicitis.

Primary closure of contaminated wounds in perforated appendicitis

We studied the clinical course of 506 children consecutively admitted with appendicitis at The Hospital for Sick Children from 1985 to 1989. One hundred eighty-one children (35%), ranging in age from 1 to 17 years, presented with perforation verified by histological examination. Ninety-six of them (53%) had generalized peritonitis, 47 (26%) had localized peritonitis, and 38 (21%) had abscess formation. Usually, triple antibiotics were begun preoperatively if perforation was suspected; otherwise, cefoxitin was started. Triple antibiotics were used postoperatively for 5 to 7 days in almost all children in the perforated group. Neither abdominal nor subcutaneous drainage was routinely used even in cases of intraabdominal abscess. The skin was closed primarily with steri-strips (63%), staples (20%), subcutaneous Dexon (11%), or silk (4%). Postoperative wound infection arose in 20 children (11%). Wound infections were noted from 1 to 14 days postoperatively (mean, 5.9 days). Whereas 9 of these were treated with local therapy only, 11 delayed the child's discharge or necessitated readmission. No patient suffered major complications from wound infection in that there were no cases of necrotizing fasciitis, reoperation for debridement, sepsis, or death. The intraabdominal abscess rate in this group of 181 children was 6% (n = 11). The low rate of infective complications fully justifies the policy of primary closure in contaminated wounds. This policy eliminates the necessity for painful and time-consuming dressing changes, shortens hospitalization, and obviates the trauma of delayed suturing of wounds in children.

Antibiotic treatment for surgical peritonitis

The charts of 480 patients with secondary bacterial peritonitis were reviewed. The antibiotics used were compared with the culture and sensitivity data obtained at surgery, and the outcomes of patients were evaluated. Patients treated with a single broad-spectrum antibiotic had a better outcome than patients treated with multiple drug treatment. Inadequate empiric antibiotic treatment was associated with poorer outcome than any other type of treatment. The outcome of this inadequate treatment group could not be improved by any antibiotic response to culture and sensitivity information after operation. Those patients treated with antibiotic coverage for anticipated organisms and having no cultures taken did as well as patients having cultures taken. Surgeons typically ignore culture data after operation, and only 8.8% of patients in this study had an appropriate change in antibiotic treatment after operation. A benefit from obtaining operative cultures could not be identified.

Appendicitis in children: current therapeutic recommendations

Wound infection is the most common source of morbidity in appendicitis. Most recent pediatric series use protocols of preoperative antibiotics with aerobic and anaerobic coverage, intraoperative lavage, no peritoneal or wound drains, and continuation of antibiotics postoperatively with complicated appendicitis. There still remains controversy concerning skin closure and the duration of antibiotic therapy. We report the results of a prospective protocol followed over 2 years with 420 children. The protocol was designed to determine whether the skin could be closed primarily in all patients undergoing appendectomy. Preoperatively all patients received triple antibiotics (ampicillin, gentamicin, and clindamycin) that were continued postoperatively for two doses if there was a normal appendix or simple acute appendicitis, for at least 3 days with gangrenous appendicitis, and at least 5 days with perforated appendicitis. Antibiotics were continued if the patient remained febrile or had a white count greater than 10,000. No drains were used and the skin was closed primarily. The overall infectious complication rate was 1.0% (4/420). Among those with a normal appendix or simple acute appendicitis there were no infectious complications. Among those with gangrenous or perforated appendicitis there were 1.7% wound infections (2/117) and 1.7% intraabdominal abscesses (2/117). Duration of hospitalization was 2.1 days (range, 1 to 5 days) after simple acute appendicitis and 6.9 days (range, 3 to 40 days) after gangrenous or perforated appendicitis. These results set new standards in terms of wound management, infectious complications, and length of hospital stay.

The bacteriology of gangrenous and perforated appendicitis--revisited

By using optimum sampling, transport, and culture techniques in patients with gangrenous or perforated appendicitis, we recovered than has previously been reported. Thirty patients older than 12 years with histologically documented gangrenous or perforated appendicitis had peritoneal fluid, appendiceal tissue, and abscess contents (if present) cultured. Appendiceal tissue was obtained so as to exclude the lumen. A total of 223 anaerobes and 82 aerobic or faculatative bacteria were recovered, an average of 10.2 different organisms per specimen. Twenty-one different genera and more than 40 species were encountered. Bacteroides fragilis group and Escherichia coli were isolated from almost all specimens. Within the B. fragilis group, eight species were represented. Other frequent isolates included Peptostreptococcus (80%), Pseudomonas (40% [P. aeruginosa, 23.3%, other Pseudomonas spp., 16.7%]), B. splanchnicus (40%), B. intermedius (36.7%), and Lactobacillus (36.7%). Interestingly a previously undescribed fastidious gram-negative anaerobic bacillus was isolated from nearly one half of all patients. This organism was found to have low DNA homology (by dot blot) with the known organisms most closely resembling it.

Newer cephalosporins: lessons to be learned from clinical trials in intraabdominal infections

Recent clinical trials testing the efficacy of newer cephalosporins in intraabdominal infections lack a number of the study design criteria proposed by Solomkin et al. Nevertheless, these trials all support the use of these newer cephalosporins in the treatment of intraabdominal infections. These newer agents demonstrate increased in vitro antimicrobial activity against potential aerobic pathogens, which suggests that they may be used in combination with an antianaerobic drug in the treatment of intraabdominal infections. Therefore, agents including cefotaxime, cefoperazone, ceftazidime, cefuroxime, ceftriaxone, and aztreonam may be chosen in place of the standard aminoglycoside. Previous studies have demonstrated the necessity of both aerobic and anaerobic coverage in empiric therapy of intraabdominal infections. Cefotetan, ceftizoxime, cefoxitin, moxalactam, mezlocillin, and piperacillin all have in vitro activity against aerobes and anaerobes (including B. fragilis), thus, these agents have a potential as monotherapy for acute intraabdominal infections in otherwise healthy patients. Directed combination chemotherapy or perhaps imipenem alone is recommended for persistent peritonitis and intraabdominal infections in immunocompromised hosts.

Acute appendicitis in children

A prospective study was conducted on 344 children aged from 3 months to 16 years with acute appendicitis. Most children presented with typical features of acute appendicitis (70%) or peritonitis (28%). Atypical presentation was uncommon and occurred only in seven young children, masquerading as intestinal obstruction, gastroenteritis or urinary tract infection. Prolonged delay in surgery was associated with a rise in incidence of late appendicitis (gangrenous and perforated appendicitis). This rise was especially marked 37 h after onset of symptoms. The main causes of delay were inability of the parents and primary care medical practitioners to recognize the disease early. Surgeons contributed very little to the delay. High risk factors for postappendectomy sepsis were young children under 6 years old, late appendicitis, obese patients, inferior systemic antibiotic regimes and inexperienced surgeons. Young children had high postoperative sepsis mainly because of the high incidence of late appendicitis due to their inability to express their symptoms properly. They were not especially prone to postappendectomy sepsis; they had the same degree of appendicitis compared with older children. Measures to decrease the postappendectomy morbidity are suggested.

Study of appendicitis in children treated with four different antibiotic regimens

This is a prospective and randomized study of 100 patients with acute appendicitis who were less than 10 years old, in which four different antibiotic regimens commonly in use against gram-negative and anaerobic bacteria were compared in terms of postoperative septic complications. The antibiotics were begun immediately preoperatively and continued for five days. Ten percent of the patients developed infection complications, with 4% requiring further surgery. The best results were obtained with cefoxitin (4% of infection), metronidazole plus amikacin and latamoxef (8%), while the regimen of clindamycin plus amikacin was associated with the greatest number of complications (20%). On analyzing the main microbiologic findings of the study, we conclude that some sort of antibiotic treatment is indicated in all types of appendicitis, due to the occult presence of bacteria in the peritoneal cavity, even without clinical evidence of gangrene or perforation. Further, we emphasize the significance of Streptococcus faecalis as being responsible, along with Escherichia coli and Bacteroides fragilis, for serious postoperative complications.