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Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
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Stewart S, Cruz-Centeno N, Marlor DR, St Peter SD, Oyetunji TA. Bridging the Gap: Pediatric General Surgery for the Pediatrician. Pediatr Rev 2023; 44:632-643. [PMID: 37907417 DOI: 10.1542/pir.2022-005894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
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Cramm SL, Chandler NM, Graham DA, Kunisaki SM, Russell RT, Blakely ML, Lipskar AM, Allukian M, Aronowitz DI, Campbell BT, Collins DT, Commander SJ, Cowles RA, DeFazio JR, Esparaz JR, Feng C, Griggs CL, Guyer RA, Hanna DN, Kahan AM, Keane OA, Lamoshi A, Lopez CM, Pace E, Regan MD, Santore MT, Scholz S, Tracy ET, Williams SA, Zhang L, Rangel SJ. Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis. Ann Surg 2023; 278:e863-e869. [PMID: 36317528 DOI: 10.1097/sla.0000000000005747] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. BACKGROUND Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision. METHODS This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. RESULTS A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. CONCLUSIONS Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.
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Affiliation(s)
- Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Robert T Russell
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron M Lipskar
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Myron Allukian
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Danielle I Aronowitz
- Division of Pediatric, General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Devon T Collins
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Sarah J Commander
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Robert A Cowles
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Jennifer R DeFazio
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
| | - Joseph R Esparaz
- Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL
| | - Christina Feng
- Department of Surgery, Children's National Hospital, Washington, DC
| | - Cornelia L Griggs
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Richard A Guyer
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David N Hanna
- Department of Surgery, Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Anastasia M Kahan
- Division of Pediatric Surgery, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos Colleges of Physicians and Surgeons, New York, NY
- Department of Surgery, Mount Sinai Health System, New York, NY
| | - Olivia A Keane
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Abdulraouf Lamoshi
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Carla M Lopez
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth Pace
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maia D Regan
- Department of Surgery, Connecticut Children's Hospital, Hartford, CT
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Stefan Scholz
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Elisabeth T Tracy
- Department of Surgery, Duke Children's Hospital and Health Center, Duke University School of Medicine, Durham, NC
| | - Sacha A Williams
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Lucy Zhang
- Division of Pediatric Surgery, Yale New Haven Children's Hospital and Yale School of Medicine, New Haven, CT
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Bălănescu R, Bălănescu L, Kadar AM, Enache T, Moga A. The Management of Pediatric Acute Appendicitis-Survey among Pediatric Surgeons in Romania. Medicina (B Aires) 2022; 58:medicina58121737. [PMID: 36556939 PMCID: PMC9781247 DOI: 10.3390/medicina58121737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives: To assess the current practice pattern in the management of pediatric acute appendicitis in Romania. Materials and Methods: A questionnaire was emailed to all the members of the Romanian Society of Pediatric Surgery between June-July 2022. Results: 118 answers were received, 79.7% responses being from permanent staff members. In the diagnosis of appendicitis, complete blood count, C-reactive protein and abdominal ultrasound are the most commonly used diagnostic tools, while appendicitis scores are not widely used (25% of surgeons). In the case of simple appendicitis, 49.2% of surgeons prefer the conservative approach-oral/intravenous antibiotics. Those who choose the operative approach begin preoperative antibiotics in 56.7% of patients. In case of a stable patient, only 16.7% of surgeons will operate during the night. Laparoscopic approach is chosen by 51.7% of surgeons. In the case of a complicated appendicitis, 92.4% of surgeons will perform the appendectomy, prescribing preoperative antibiotics in 94% of the cases and continuing the therapy postoperatively in 98.2%. Laparoscopic approach is used by 28.8% of surgeons in case of complicated appendicitis. In presence of appendicular mass, 80% prefer a conservative approach with a delayed appendectomy within 6 months. Appendicular abscesses are managed operatively in 82.2% of the cases. The appendix is sent for histological analysis by 95.8% of surgeons. If the peritoneal cavity is contaminated, 95% of the respondents will take a sample for microbiological analysis, 71% will always place a drainage and 44% will always irrigate (71.9%-saline). Conclusions: Clearly, there seems to be a lack of consensus regarding several aspects of the management of acute appendicitis in children. In addition, minimally invasive surgery is not as widely used as reported, despite literature support.
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Affiliation(s)
- Radu Bălănescu
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Laura Bălănescu
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Correspondence: ; Tel.: +40-722984347
| | - Anna Maria Kadar
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Pediatric Surgery Department, “M.S. Curie” Clinical Emergency Hospital for Children, 077120 Bucharest, Romania
| | - Tudor Enache
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
| | - Andreea Moga
- Pediatric Surgery Department, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
- Department of Pediatric Surgery and Orthopedics, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Kwok CPD, Tsui SYB, Chan KWE. Updates on bacterial resistance and empirical antibiotics treatment of complicated acute appendicitis in children. J Pediatr Surg 2021; 56:1145-1149. [PMID: 33845984 DOI: 10.1016/j.jpedsurg.2021.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Chun Pong Daniel Kwok
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong.
| | - Siu Yan Bess Tsui
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Kin Wai Edwin Chan
- Division of Paediatric Surgery and Paediatric Urology, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
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Dabaja-Younis H, Farah H, Miron R, Geffen Y, Slijper N, Steinberg R, Kassis I. The intraperitoneal bacteriology and antimicrobial resistance in acute appendicitis among children: a retrospective cohort study between the years 2007-2017. Eur J Pediatr 2021; 180:2091-2098. [PMID: 33594543 DOI: 10.1007/s00431-021-03994-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/24/2022]
Abstract
This study aims to describe the microbiology and susceptibility profile of the intraperitoneal flora in complicated appendicitis. It is a retrospective cohort study including children < 18-year-old with pathologically confirmed appendicitis, from 2007 to 2017. It included 1466 children. Intraperitoneal samples were obtained from 655 (44.7%) patients, and 201 (30.7%) had positive culture with 395 pathogens. Gram-negative rods comprised 67.6%, Gram-positive cocci 21.5%, and anaerobes 10.9% of the isolates. Gram-positive cocci were detected in 67 (37.8%) patients. Milleri group Streptococci was the most frequently isolated Gram-positive (44.7%). The proportional rate of Milleri group Streptococci from Gram-positive cocci increased from 9.5 to 56.3% (P < 0.001, OR 12.214). Patients with Gram-positive cocci had longer hospital stay (mean 9.36 + 6.385 vs 7.72 + 4.582, P = 0.036, (CI -3.165, -0.105)) and more complicated disease (89.5% vs 78.4%, P = 0.045, OR 2.342). Patients with Milleri group Streptococci isolates readmitted more frequently (26.5% vs 13.2%, P = 0.05, OR 2.37). Resistance to amoxicillin-clavulanate, gentamicin, ceftazidime, piperacillin-tazobactam, and amikacin were detected in 29.1%, 6.5%, 2.3%, 1.2%, and 0.7% of the Gram-negative rods, respectively.Conclusion: The rates of Gram-positive cocci and particularly Milleri group Streptococci in peritoneal fluid are increasing. More complicated disease and longer hospital stay in Gram-positive cocci and higher readmission rate in Milleri group Streptococci. These emphasize the role of anti-Gram-positive antimicrobials. What is known: • Gram-negative rods are the main isolates in complicated appendicitis. • The choice of antibiotic regimen is an unsettled issue due to resistance. What is new: • Increased rate of Gram-positive cocci and Milleri group Streptococci. • More complicated disease, longer hospital stay, and higher readmission rate.
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Affiliation(s)
- Halima Dabaja-Younis
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel.
| | - Hanna Farah
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
| | - Ran Miron
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
| | - Yuval Geffen
- Microbiology Laboratory, Rambam Healthcare Center, Haifa, Israel
| | - Nadav Slijper
- Pediatric Surgery Department, Rambam Healthcare Center, Haifa, Israel
| | - Ran Steinberg
- Pediatric Surgery Department, Rambam Healthcare Center, Haifa, Israel
| | - Imad Kassis
- Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel
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Roque FMCB, Melo Filho AA, Roque AJCB, Roque HCB, Moreira TMM, Chaves EMC. ANTIBIOTICS FOR APPENDICECTOMY IN CHILDREN AND ADOLESCENTS DURING THE PERIOPERATIVE PERIOD: AN INTEGRATIVE REVIEW. REVISTA PAULISTA DE PEDIATRIA 2019; 37:494-502. [PMID: 31291445 PMCID: PMC6821483 DOI: 10.1590/1984-0462/;2019;37;4;00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/07/2018] [Indexed: 11/21/2022]
Abstract
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.
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Intravenous versus intravenous/oral antibiotics for perforated appendicitis in pediatric patients: a systematic review and meta-analysis. BMC Pediatr 2019; 19:407. [PMID: 31684906 PMCID: PMC6827245 DOI: 10.1186/s12887-019-1799-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023] Open
Abstract
Background The use of oral (PO) antibiotics following a course of certain intravenous (IV) antibiotics is proposed in order to avoid the complications of IV medications and to decrease the cost. However, the efficacy and safety of sequential IV/PO antibiotics is unclear and requires further study. Methods The databases, including PubMed, EMBASE and Cochrane Library, were searched. Studies comparing outcomes in patients with perforated appendicitis receiving sequential IV/PO and PO antibiotics therapy were screened. The Newcastle-Ottawa Scale (NOS) and the Jadad score were used to evaluate the quality of the cohort and the randomized controlled portions of the trial, respectively. Statistical heterogeneity was assessed using the I2 value. A fixed or random-effect model was applied according to the I2 value. Results Five controlled studies including a total of 580 patients were evaluated. The pooled estimates revealed that sequential IV/PO antibiotic therapy did not increase the risk of complications, with a risk ratio (RR) of 0.97 (95% CI 0.51–1.83, P = 0.93) for postoperative abscess, 1.04 (95% CI 0.25–4.36, P = 0.96) for wound infection and 0.62 (95% CI 0.33–1.16, P = 0.13) for readmission. Conclusions Our study demonstrates that sequential IV/PO antibiotic therapy is noninferior to IV antibiotic therapy regarding postoperative abscess, wound infection and readmission.
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Extended Versus Narrow-spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: A Propensity-matched Comparative Effectiveness Study. Ann Surg 2019; 268:186-192. [PMID: 28654543 DOI: 10.1097/sla.0000000000002349] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis. SUMMARY OF BACKGROUND DATA There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis. METHODS Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates. RESULTS Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)]. CONCLUSIONS Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.
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Bonasso PC, Dassinger MS, Wyrick DL, Smith SD, Burford JM. Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis. Am J Surg 2019; 217:1099-1101. [PMID: 30639131 DOI: 10.1016/j.amjsurg.2018.12.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
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Anderson KT, Bartz-Kurycki MA, Kawaguchi AL, Austin MT, Holzmann-Pazgal G, Kao LS, Lally KP, Tsao K. Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe? J Am Coll Surg 2018; 227:247-254. [PMID: 29680415 DOI: 10.1016/j.jamcollsurg.2018.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
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12
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Taleb M, Nardi N, Arnaud A, Costet N, Donnio PY, Engrand C, Habonimana E, Wodey E, Tattevin P. Simplification of first-line antibacterial regimen for complicated appendicitis in children is associated with better adherence to guidelines and reduced use of antibiotics. Int J Antimicrob Agents 2018; 52:293-296. [PMID: 29678565 DOI: 10.1016/j.ijantimicag.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 04/01/2018] [Accepted: 04/09/2018] [Indexed: 01/25/2023]
Abstract
Acute appendicitis in children requires early surgery and short-course antibiotics active against Enterobacteriaceae and anaerobes. Although an aminoglycoside-containing three-drug regimen has been used successfully for decades, simpler regimens with similar efficacy are increasingly used. This study evaluated the impact of a switch from the combination of cefotaxime, metronidazole and gentamicin (regimen 1) to piperacillin/tazobactam (regimen 2) as first-line regimen for complicated acute appendicitis in children. In total, 171 children were enrolled [median (IQR) age, 10 (6-13) years], treated with regimen 1 (n = 80) or regimen 2 (n = 91) following surgery for complicated acute appendicitis. The two groups were comparable except for surgical approach (through laparoscopy in 46% vs. 88% for regimens 1 and 2, respectively; P < 0.001). Post-operative complications and duration of hospital stay were similar. Deviations from antibacterial treatment protocol decreased from 36% (29/80) to 14% (13/91) (P < 0.001), with a dramatic reduction in antibacterial treatment duration from median (IQR) of 15 (12-16) days to 5 (5-8) days (P < 0.001). Post-operative intra-abdominal abscess developed in 32 children (18.7%). Female sex (OR = 2.76, 95% CI 1.18-6.48; P = 0.02) and sepsis/septic shock on admission (OR = 4.72, 95% CI 1.12-19.97; P = 0.035) were independently associated with post-operative intra-abdominal abscess, but not antibacterial regimen. This study shows that simplification of first-line antibacterial regimen for complicated appendicitis in children was associated with reduced protocol deviation, reduced duration of antibiotics, and similar outcomes (post-operative complications and duration of hospital stay).
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Affiliation(s)
- Marion Taleb
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Nicolas Nardi
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Alexis Arnaud
- Department of Pediatric Surgery, Rennes University Hospital, Rennes, France
| | - Nathalie Costet
- Department of Biostatistics UMR Inserm 1099 LTSI Rennes 1 University, Rennes, France
| | - Pierre-Yves Donnio
- Department of Infection Control and Prevention, Rennes University Hospital, Rennes, France
| | - Charlotte Engrand
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Edouard Habonimana
- Department of Pediatric Surgery, Rennes University Hospital, Rennes, France
| | - Eric Wodey
- Department of Anesthesiology, Rennes University Hospital, Rennes, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Rennes University Hospital, Rennes, France.
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Abstract
Acute appendicitis is the most common reason for abdominal surgery in children. Luminal obstruction of the appendix progresses to suppurative inflammation and perforation, which causes generalised peritonitis or an appendix mass/abscess. Classical features include periumbilical pain that migrates to the right iliac fossa, anorexia, fever, and tenderness and guarding in the right iliac fossa. Atypical presentations are particularly common in preschool children. A clinical diagnosis is possible in most cases, after a period of active observation if necessary; inflammatory markers and an ultrasound scan are useful investigations when the diagnosis is uncertain. Treatment is by appendicectomy after appropriate fluid resuscitation, analgesia and intravenous antibiotics. Laparoscopic appendicectomy is better than open appendicectomy in most cases because it is associated with less postoperative pain and a shorter hospital stay, but recovery after acute appendicitis is mostly dictated by whether the appendix was perforated or not. Management of the appendix mass remains controversial and not all affected children need an interval appendicectomy. This article discusses tips and pitfalls in diagnosis and addresses many of the controversies that surround the management of this condition.
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Affiliation(s)
- Mark D Stringer
- Department of Paediatric Surgery and Child Health, Wellington Hospital, Wellington, New Zealand
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Dickinson CM, Coppersmith NA, Luks FI. Early Predictors of Abscess Development after Perforated Pediatric Appendicitis. Surg Infect (Larchmt) 2017; 18:886-889. [PMID: 29016242 DOI: 10.1089/sur.2017.134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Approximately one-third of children with appendicitis present with advanced disease or perforation. Whereas this increases the risk for post-operative complications and re-admission, it is not yet possible to predict early on who will develop an abdominal abscess. We sought to identify specific risk factors for this complication, in an attempt to streamline post-operative care. PATIENTS AND METHODS We reviewed the records of all cases of perforated appendicitis over a 12-month period at a tertiary children's hospital. All patients who developed an abscess despite treatment minimum of seven days of antibiotic therapy were identified. Patients who presented or were re-admitted with an abscess were excluded from analysis. Records were reviewed for demographics, laboratory results, progression of oral intake, and vital signs. RESULTS Of 273 patients with appendicitis, we identified 59 cases of perforated appendicitis. Fifteen patients were excluded. Eight of the remaining 44 patients (18.2%) developed an abscess during their initial admission. Their mean length of stay was longer than that of patients without an abscess (13.4 ± 7.1 vs. 6.9 ± 1.9 d, p < 0.0001). Gender, leukocytosis, or diarrhea at presentation, maximum temperature on post-operative day 3, and maximum heart rate on post-operative day 3 were not statistically different. Diet progression was different between the two groups: none of the 21 patients who were tolerating a regular diet by post-operative day 3 developed an abscess, compared with 8 of the 23 patients who were not yet eating a regular diet on post-operative day 3 (p < 0.01). Late leukocytosis also correlated with the presence of an abscess: 7 of the 8 patients with an abscess had persistent leukocytosis at days 5 through 7, compared with 3 of 31 patients without abscess (p < 0.05). An ultrasound was obtained for these 3 patients and proved normal. CONCLUSIONS Tolerating a regular diet three days after appendectomy for perforated appendicitis decreased the likelihood of a post-operative abscess. No other parameter was predictive of this complication early in the post-operative period. If confirmed in a larger prospective study, this finding may help decrease the length of stay for low-risk patients, and identify abscesses in high-risk patients in a timely fashion.
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Affiliation(s)
- Catherine M Dickinson
- 1 Department of Surgery, Warren Alpert Medical School of Brown University , Rhode Island Hospital, Providence, Rhode Island
| | | | - Francois I Luks
- 3 Department of Surgery, Division of Pediatric Surgery, Warren Alpert Medical School of Brown University , Providence, Rhode Island.,4 Division of Pediatric Surgery, Hasbro Children's Hospital , Providence, Rhode Island
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15
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Mueck KM, Putnam LR, Anderson KT, Lally KP, Tsao K, Kao LS. Does compliance with antibiotic prophylaxis in pediatric simple appendicitis matter? J Surg Res 2017; 216:1-8. [DOI: 10.1016/j.jss.2017.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/31/2017] [Accepted: 04/11/2017] [Indexed: 12/17/2022]
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16
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 317] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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Altokhais TI, Al-Obaid OA, Kattan AE, Amer YS. Assessment of implementability of an adapted clinical practice guideline for surgical antimicrobial prophylaxis at a tertiary care university hospital. J Eval Clin Pract 2017; 23:156-164. [PMID: 27807920 DOI: 10.1111/jep.12658] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 08/28/2016] [Accepted: 08/29/2016] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Surgical site infections are the most common healthcare-associated infections. Appropriate surgical antimicrobial prophylaxis (SAP), which is an integral part of surgical site infection SSI prevention, is one of the major preventable risks to surgical patient safety. Several clinical practice guidelines (CPGs) for SAP have been published. The aim of this study was to adapt a CPG for SAP and to assess its implementability. METHODS The methodology was based on two validated tools for CPGs, namely, the ADAPTE and the Guideline Implementability Appraisal (GLIA). RESULTS The ADAPTE CPG adaptation process methodology was utilized to produce an adapted CPG for SAP based on the American Society of Health System Pharmacists 2013 CPG. The finalized CPG was then assessed to identify any possible intrinsic barriers for implementation. CONCLUSIONS In conclusion, the ADAPTE tool is a practical and successful tool for production of CPGs. The GLIA tool is useful for assessing and preparing the finalized adapted CPG for the transition from the production stage to the implementation stage. GLIA could be added to the ADAPTE process either as a final step or to check the draft of the CPG before finalization.
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Affiliation(s)
- Tariq I Altokhais
- Division of Pediatric Surgery, Department of Surgery, Surgery Departmental CPG Committee, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Omar A Al-Obaid
- Division of Colorectal Surgery, Department of Surgery, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah E Kattan
- Division of Plastic Surgery, Department of Surgery, Surgery Departmental Quality Team, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Yasser S Amer
- Quality Management Department, CPG Steering Committee, Research Chair for Evidence-based Health Care and Knowledge Translation, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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- King Saud University Medical City, Riyadh, Saudi Arabia
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18
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Willis ZI, Duggan EM, Bucher BT, Pietsch JB, Milovancev M, Wharton W, Gillon J, Lovvorn HN, O'Neill JA, Di Pentima MC, Blakely ML. Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis. JAMA Surg 2016; 151:e160194. [PMID: 27027263 DOI: 10.1001/jamasurg.2016.0194] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE Complicated appendicitis is a common condition in children that causes substantial morbidity. Significant variation in practice exists within and between centers. We observed highly variable practices within our hospital and hypothesized that a clinical practice guideline (CPG) would standardize care and be associated with improved patient outcomes. OBJECTIVE To determine whether a CPG for complicated appendicitis could be associated with improved clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A comprehensive CPG was developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt, a freestanding children's hospital in Nashville, Tennessee, and was implemented in July 2013. All patients with complicated appendicitis who were treated with early appendectomy during the study period were included in the study. Patients were divided into 2 cohorts, based on whether they were treated before or after CPG implementation. Clinical characteristics and outcomes were recorded for 30 months prior to and 16 months following CPG implementation. EXPOSURE Clinical practice guideline developed for all children with complicated appendicitis at Monroe Carell Jr Children's Hospital at Vanderbilt. MAIN OUTCOMES AND MEASURES The primary outcome measure was the occurrence of any adverse event such as readmission or surgical site infection. In addition, resource use, practice variation, and CPG adherence were assessed. RESULTS Of the 313 patients included in the study, 183 were boys (58.5%) and 234 were white (74.8%). Complete CPG adherence occurred in 78.7% of cases (n = 96). The pre-CPG group included 191 patients with a mean (SD) age of 8.8 (4.0) years, and the post-CPG group included 122 patients with a mean (SD) age of 8.7 (4.1) years. Compared with the pre-CPG group, patients in the post-CPG group were less likely to receive a peripherally inserted central catheter (2.5%, n = 3 vs 30.4%, n = 58; P < .001) or require a postoperative computed tomographic scan (13.1%, n = 16 vs 29.3%, n = 56; P = .001), and length of hospital stay was significantly reduced (4.6 days post-CPG vs 5.1 days pre-CPG, P < .05). Patients in the post-CPG group were less likely to have a surgical site infection (relative risk [RR], 0.41; 95% CI, 0.27-0.74) or require a second operation (RR, 0.35; 95% CI, 0.12-1.00). In the pre-CPG group, 30.9% of patients (n = 59) experienced any adverse event, while 22.1% of post-CPG patients (n = 27) experienced any adverse event (RR, 0.72; 95% CI, 0.48-1.06). CONCLUSIONS AND RELEVANCE Significant practice variation exists among surgeons in the management of pediatric complicated appendicitis. In our institution, a CPG that standardized practice patterns was associated with reduced resource use and improved patient outcomes. Most surgeons had very high compliance with the CPG.
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Affiliation(s)
- Zachary I Willis
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eileen M Duggan
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Brian T Bucher
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee3Division of Pediatric Surgery, University of Utah, Salt Lake City
| | - John B Pietsch
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Monica Milovancev
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Whitney Wharton
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jessica Gillon
- Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James A O'Neill
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - M Cecilia Di Pentima
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Martin L Blakely
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
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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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20
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Thompson GC, Schuh S, Gravel J, Reid S, Fitzpatrick E, Turner T, Bhatt M, Beer D, Blair G, Eccles R, Jones S, Kilgar J, Liston N, Martin J, Hagel B, Nettel-Aguirre A. Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals. Acad Emerg Med 2015; 22:811-22. [PMID: 26130319 DOI: 10.1111/acem.12709] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/12/2014] [Accepted: 01/12/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. METHODS Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. RESULTS Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). CONCLUSIONS Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.
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Affiliation(s)
- Graham C. Thompson
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
| | - Suzanne Schuh
- Hospital for Sick Children; University of Toronto; Toronto ON
| | - Jocelyn Gravel
- Centre Hospitalier Universitaire Ste-Justine; Universite de Montreal; Montreal QC
| | - Sarah Reid
- Children's Hospital of Eastern Ontario; University of Ottawa; Ottawa ON
| | | | - Troy Turner
- Stollery Children's Hospital; University of Alberta; Edmonton AB
| | - Maala Bhatt
- Hospital for Sick Children; University of Toronto; Toronto ON
| | - Darcy Beer
- Winnipeg Children's Hospital; University of Manitoba; Winnipeg MB
| | - Geoffrey Blair
- British Columbia Children's Hospital; University of British Columbia; Vancouver BC
| | - Robin Eccles
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
| | - Sarah Jones
- Children's Hospital London Health Sciences Centre; Western University; London ON
| | - Jennifer Kilgar
- Children's Hospital London Health Sciences Centre; Western University; London ON
| | - Natalia Liston
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
| | - John Martin
- Janeway Children's Health and Rehabilitation Centre; Memorial University; St. John's NL
| | - Brent Hagel
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
- Department of Community Health Sciences; University of Calgary; Calgary AB
| | - Alberto Nettel-Aguirre
- Alberta Children's Hospital Research Institute and Department of Pediatrics; University of Calgary; Calgary AB
- Department of Community Health Sciences; University of Calgary; Calgary AB
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Affiliation(s)
- Daniel E Levin
- Department of General Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Walter Pegoli
- Department of General Surgery, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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22
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Affiliation(s)
- Ki Hoon Kim
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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23
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A dynamic postoperative protocol provides efficient care for pediatric patients with non-ruptured appendicitis. J Pediatr Surg 2015; 50:149-52. [PMID: 25598113 DOI: 10.1016/j.jpedsurg.2014.10.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 10/06/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE Postoperative management of pediatric patients with non-ruptured appendicitis is highly variable and often includes an overnight stay in the hospital. We implemented a criteria-based postoperative protocol designed to eliminate postoperative antibiotics and facilitate timely discharge by utilizing the bedside nurse to evaluate for readiness for discharge. METHODS We collected data on all patients with non-ruptured appendicitis at our institution following protocol implementation (May 1, 2012 to April 30, 2013) and compared them to a control group. RESULTS 580 patients were treated for non-ruptured appendicitis (285 prior protocol, 295 new protocol). Following implementation of our protocol, there was an overall reduction in length of stay from 40.1 (SD 27.5) to 23.5 (SD 20.8)h, and total cost of care per patient also decreased from $5783 (SD $2501) to $4499 (SD $1983) (p<0.001). There was no change in hospital readmission rate (1.1% prior protocol, 1.4% new protocol) or postoperative abscess rate (0.8% prior protocol, 0.3% new protocol). CONCLUSION Our new protocol reveals the value of eliminating postoperative antibiotics and leveraging the continuous availability of the bedside nurse in the determination of readiness for discharge.
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[Comparison of two protocols of prophylactic antibiotic therapy in childhood appendectomy]. Arch Pediatr 2014; 21:1167-72. [PMID: 25282456 DOI: 10.1016/j.arcped.2014.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 06/19/2014] [Accepted: 08/04/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Antibiotic administration during acute appendicitis in children continues to be debated. The purpose of this study was to compare efficacy of two prophylactic antibiotic treatment guidelines in acute appendicitis and peritonitis in children. MATERIEL AND METHODS The infectious complication rate after appendicectomy was compared during two distinct periods (before/after study). During the first period, the guidelines for antibiotic administration were based on ticarcillin-clavulanic acid. During the second period, the guidelines were based on amoxicillin-clavulanic acid for non-perforated appendicitis or appendicitis with localized peritonitis, and clavulanic acid was reserved for general peritonitis. All children younger than 16 years of age who underwent appendicectomy during the periods studied were included. Data were retrospectively collected from surgical and anesthetics charts. RESULTS Ninety-five children during the first period and 238 during the second were included. In the children with non-perforated appendicitis, no postoperative infectious complication occurred in 74 children during the first period versus two out of 153 (1%) during the second period. In cases of perforated appendicitis, postoperative infectious complications occurred two cases (10%) during the first period versus nine (11%) during the second. There were no significant differences between the two periods. CONCLUSION In this population, antibiotic administration guidelines based on amoxicillin-clavulanic acid for stages I-III of appendicitis maintained a low rate of postoperative infectious complications and were not associated with a higher postoperative infectious complication rate than guidelines based on ticarcillin-clavulanic acid.
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Standardization and improvement of care for pediatric patients with perforated appendicitis. J Pediatr Surg 2014; 49:1020-4; discussion 1024-5. [PMID: 24888855 DOI: 10.1016/j.jpedsurg.2014.01.045] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 01/27/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE Reduction of treatment variation and application of evidenced based care are increasingly important in the current care environment. Utilizing formal quality improvement methods, an evidenced based guideline was implemented at our institution. METHODS A guideline was established regarding timing of surgery (immediate vs interval appendectomy) and duration of antibiotics. Twelve months of baseline data were collected prior to implementation. The guideline dictates immediate appendectomy (IA) and postoperative antibiotic therapy until discharge (regular diet, clinically improved, normal complete blood count (CBC)). Data was collected prospectively during hospitalization and at 30days postdischarge. Control charts document adherence to the overall guideline, IA, antibiotic guideline, and readmission for complications. RESULTS Guideline implementation resulted in an increase in IA (79% vs 94%), decrease in the use of IV antibiotics post discharge (25% to 4%), no change in overall LOS, no change in postoperative abscess formation, and slight decrease in 30day readmission. Charges were decreased. CONCLUSION Implementation of an evidenced based guideline resulted in significant practice change for managing perforated appendicitis. The changes suggest more efficient care without compromising patient outcome. Utilization of quality improvement methods allows for implementing and tracking the change as well as creating a platform for future improvement.
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van Rossem CC, Schreinemacher MHF, Treskes K, van Hogezand RM, van Geloven AAW. Duration of antibiotic treatment after appendicectomy for acute complicated appendicitis. Br J Surg 2014; 101:715-9. [PMID: 24668341 DOI: 10.1002/bjs.9481] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Antibiotic treatment after appendicectomy for complicated appendicitis aims to reduce postoperative infections. However, available data on the duration of treatment are limited. This study compared the difference in infectious complications between two protocols, involving either 3 or 5 days of postoperative antibiotic treatment. METHODS This was an observational cohort study of all adult patients who had an appendicectomy between January 2004 and December 2010 at either one of two hospitals in the same region. At location A, the protocol included 3 days of postoperative antibiotic treatment, whereas at location B it specified 5 days. The primary outcome was the development of postoperative infections as either superficial wound infection or deep intra-abdominal infections. RESULTS A total of 1143 patients with acute appendicitis underwent appendicectomy, of whom 267 (23.4 per cent) had complicated appendicitis. The duration of postoperative antibiotic treatment was 3 days in 135 patients (50.6 per cent) and at least 5 days in 123 (46.1 per cent). No difference was found between antibiotic treatment for 3 or 5 days in terms of developing an intra-abdominal abscess (odds ratio (OR) 1.77, 95 per cent confidence interval 0.68 to 4.58; P = 0.242) or a wound infection (OR 2.74, 0.54 to 13.80; P = 0.223). In patients with complicated appendicitis, the laparoscopic approach was identified as a risk factor for developing an intra-abdominal abscess in univariable analysis (OR 2.46, 1.00 to 6.04; P = 0.049), but was not confirmed as an independent risk factor for this complication in multivariable analysis (OR 2.32, 0.75 to 7.14; P = 0.144). CONCLUSION After appendicectomy for complicated appendicitis, 3 days of antibiotic treatment is equally effective as 5 days in reducing postoperative infections.
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Affiliation(s)
- C C van Rossem
- Department of Surgery, Tergooi Hospital, PO Box 10016, 1201 DA Hilversum, The Netherlands
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Gerber JS, Kronman MP, Ross RK, Hersh AL, Newland JG, Metjian TA, Zaoutis TE. Identifying targets for antimicrobial stewardship in children's hospitals. Infect Control Hosp Epidemiol 2013; 34:1252-8. [PMID: 24225609 DOI: 10.1086/673982] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Antimicrobial stewardship programs (ASPs) are recommended to optimize antimicrobial use for hospitalized patients. Although mechanisms for the implementation of ASPs have been described, data-driven approaches to prioritize specific conditions and antimicrobials for intervention have not been established. We aimed to develop a strategy for identifying high-impact targets for antimicrobial stewardship efforts. DESIGN Retrospective cross-sectional study. SETTING AND PATIENTS Children admitted to 32 freestanding children's hospitals in the United States in 2010. METHODS We identified the conditions with the largest proportional contribution to the total days of antibiotic therapy prescribed to all hospitalized children. For the 4 highest-using conditions, we examined variability between hospitals in antibiotic selection patterns for use of either first- or second-line therapies depending on the condition. Antibiotic use was determined using standardized probability of exposure to selected agents and standardized days of therapy per 1,000 patient-days, adjusting for patient demographics and severity of illness. RESULTS In 2010, 524,364 children received 2,082,929 days of antibiotic therapy. Surgical patients received 43% of all antibiotics. The 4 highest-using conditions-pneumonia, appendicitis, cystic fibrosis, and skin and soft-tissue infection-represent 1% of all conditions yet accounted for more than 10% of all antibiotic use. Wide variability in antibiotic use occurred for 3 of these 4 conditions. CONCLUSIONS Antibiotic use in children's hospitals varied broadly across institutions when examining diagnoses individually and adjusting for severity of illness. Identifying conditions with both frequent and variable antimicrobial use informs the prioritization of high-impact targets for future antimicrobial stewardship interventions.
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Affiliation(s)
- Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Dodds PR, Meinke AK, Lincer RM, Fitzgerald EJ, Dodds JH. Inter-rater concordance of wound classifications in patients undergoing appendectomy. Surg Infect (Larchmt) 2013; 14:445-50. [PMID: 23991652 DOI: 10.1089/sur.2012.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Despite the widespread utilization of a four-stage wound classification system to risk-adjust operations for surgical site infection (SSI) rates, we are not aware of any study evaluating the definitions of the wound classes for clarity. We limited our study of wound classifications to appendectomies and posed the question whether different reviewers classify individual cases differently. METHODS We evaluated the wound classifications of 105 consecutive appendectomies in our community hospital. Four reviewers graded retrospectively the wound classifications, first after reading the description of the appendix in the operative report and again after reading the pathology report. The wound classifications of the four reviewers were evaluated for concordance with the original operating room nurse (ORN) assignment. RESULTS The kappa scores for inter-observer concordance of wound classifications among the four reviewers based on their interpretation of the operative report and the ORN who originally classified the operation ranged from 0.1028 to 0.1597. By conventional standards, this represents no better than "slight agreement" for any of the reviewers. We found that 19%, 50%, 94%, 95%, or 96% of our appendectomies would be considered "high risk," Class 3 or 4, operations depending on which rater classified the operation. The additional information contained in the pathology reports did not change the distribution of wound classifications of the four reviewers significantly. CONCLUSIONS Our study demonstrated considerable differences in the distribution of wound classifications of appendectomies among our ORNs and retrospective reviewers. A review of the surgical literature supports our finding that the incision classification system utilized commonly lacks precision, at least in the rating of appendectomies. We recommend that further studies be performed to determine whether changes in the definitions of wound classes are warranted.
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Affiliation(s)
- Peter R Dodds
- 1 Department of Surgery, Norwalk Hospital , Norwalk, Connecticut
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Chen CW, Chu CM, Ma CJ, Shan YS, Yeh YS, Wang JY. Prospective, Randomized, Study of Ampicillin-Sulbactam versus Moxifloxacin Monotherapy for the Treatment of Community-Acquired Complicated Intra-Abdominal Infections. Surg Infect (Larchmt) 2013; 14:389-96. [DOI: 10.1089/sur.2012.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Chao-Wen Chen
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Ming Chu
- Section of Biostatistics and Informatics, Department of Epidemiology, School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Jen Ma
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Shen Shan
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yung-Sung Yeh
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Department of Surgery, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Genetics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73-156. [PMID: 23461695 DOI: 10.1089/sur.2013.9999] [Citation(s) in RCA: 690] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Dale W Bratzler
- College of Public Health, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma 73126-0901, USA.
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Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. [DOI: 10.2146/ajhp120568] [Citation(s) in RCA: 1364] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Bacteriology of Acute Appendicitis and Its Implication for the Use of Prophylactic Antibiotics. Surg Infect (Larchmt) 2012; 13:383-90. [PMID: 23231389 DOI: 10.1089/sur.2011.135] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Mouaffak Y, Boutbaoucht M, Soraa N, Chabaa L, Salama T, Oulad Saiad M, Younous S. [Bacteriology of community-acquired peritonitis in children treated in the university hospital of Marrakech]. ACTA ACUST UNITED AC 2012. [PMID: 23199846 DOI: 10.1016/j.annfar.2012.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The available microbiological data on community-acquired peritonitis in children are inadequate, and antibiotic therapy is not consensual. Our work aims to study the bacteriology of peritonitis in children in our region and discuss the appropriate antibiotherapy. PATIENTS AND METHODS A descriptive study spread over one year. We collected cases of peritonitis in which a microbiological study of peritoneal fluid was performed. RESULTS Of 38 cases, the most frequently isolated bacteria is Escherichia coli (E. coli) (50%). Its sensitivity was 64% to amoxicillin-clavulanate, 93.33% to third generation cephalosporins (C3G) and 100% to ertapenem and aminozides. CONCLUSION We find a high rate of resistance of E. coli to amoxicillin-clavulanic acid. This prompts us to reconsider our therapeutic approach. We believe that the association C3G+aminoglycoside+metronidazole should be used first-line in the pediatric peritonitis in our context.
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Affiliation(s)
- Y Mouaffak
- Service d'anesthésie-réanimation pédiatrique, hôpital Mère-Enfant, CHU Mohammed VI, université Cadi Ayyad, rue Ibn Sina, Amerchich, Marrakech, Maroc
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Berthe-Aucejo A, Postaire M, Cheikhlard A, Zahar JR, Bourget P. [Antibiotic treatment of appendicular peritonitis in children: is the oral route done?]. Arch Pediatr 2012; 19:1303-7. [PMID: 23107091 DOI: 10.1016/j.arcped.2012.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 07/04/2012] [Accepted: 09/24/2012] [Indexed: 11/26/2022]
Abstract
The use of intravenously administered antibiotics has several disadvantages including hospitalization costs, infectious risk, and patient discomfort. The objective of this study was to estimate the proportion of children receiving intravenous antibiotic therapy (IV), for whom there was a switch to an oral route conforming to the criteria established by the American Pediatric Surgical Association (APSA). A cohort of 100 children hospitalized for acute appendicitis with generalized peritonitis or abscess were analyzed. In this study, we compared the criteria of switching to an oral route as recommended by the APSA (disappearance of the pain, normalization of white blood cells, afebrile for 48 hours, return to bowel function) and by reports from the literature (afebrile, tolerating regular diet). In 47.5% of the children, there was a switch to an oral route conforming to the APSA recommendations. In children having a late switch, the average duration of the IV treatment was of 7.6 ± 3.6 days associated with 62 days of avoidable IV antibiotics. The duration of hospitalization and antibiotic treatment was significantly higher in children having a late switch (P=0.04; P=0.01, respectively). Concerning the criteria reported in the literature, 14.5% of children were not switched to an oral route. Meeting the criteria from the literature would have resulted in 199 days of avoidable IV antibiotics. A significant number of days of IV antibiotics could have been avoided. However, the large number of exclusion criteria in the APSA analysis suggests that practitioners do not follow these recommendations or objective criteria. The criteria proposed in the literature could decrease the duration of IV antibiotics and the associated hospitalization costs.
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Affiliation(s)
- A Berthe-Aucejo
- Service de pharmacie, groupement hospitalier Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France.
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Abstract
PURPOSE OF REVIEW Surgical site infection (SSI) is one of the most common complications of surgery in both adults and children. The purpose of the present review is to highlight the progress in the understanding of SSIs and the current role of antimicrobial prophylaxis (AMP). RECENT FINDINGS An SSI is diagnosed by a constellation of clinical findings occurring within 30 days of surgery. Pathologic organisms responsible for the development of an SSI are mainly limited to Gram-positive bacteria. Two well documented risk factors for the development of SSI in children are wound classification by the Centers for Disease Control (CDC) and procedure duration. Administration of appropriate AMP prior to skin incision has been shown to reduce the incidence of SSI in selected procedures. However, there is a lack of consensus on which procedures in children require AMP. SUMMARY Improvement in the perioperative care of children has reduced both the incidence and outcomes of SSI. However, several controversies still exist in the use of AMP in children. Future work by pediatricians, pediatric surgeons, and pediatric infectious disease specialists will enable us to better understand the specific indications and appropriate AMP in children.
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Affiliation(s)
- Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Prolonged antibiotic treatment does not prevent intra-abdominal abscesses in perforated appendicitis. World J Surg 2011; 34:3049-53. [PMID: 20809151 PMCID: PMC2982962 DOI: 10.1007/s00268-010-0767-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Children with perforated appendicitis have a relatively high risk of intra-abdominal abscesses. There is no evidence that prolonged antibiotic treatment after surgery reduces intra-abdominal abscess formation. We compared two patient groups with perforated appendicitis with different postoperative antibiotic treatment protocols. Methods We retrospectively reviewed patients younger than age 18 years who underwent appendectomy for perforated appendicitis at two academic hospitals between January 1992 and December 2006. Perforation was diagnosed during surgery and confirmed during histopathological evaluation. Patients in hospital A received 5 days of antibiotics postoperatively, unless decided otherwise on clinical grounds. Patients in hospital B received antibiotics for 5 days, continued until serum C-reactive protein (CRP) was <20 mg/l. Univariate logistic regression analysis was performed on intention-to-treat basis. p < 0.05 was considered significant. Results A total of 149 children underwent appendectomy for perforated appendicitis: 68 in hospital A, and 81 in hospital B. As expected, the median (range) use of antibiotics was significantly different: 5 (range, 1–16) and 7 (range, 2–32) days, respectively (p < 0.0001). However, the incidence of postoperative intra-abdominal abscesses was similar (p = 0.95). Regression analysis demonstrated that sex (female) was a risk factor for abscess formation, whereas surgical technique and young age were not. Conclusions Prolonged use of antibiotics after surgery for perforated appendicitis in children based on serum CRP does not reduce postoperative abscess formation.
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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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Vons C. Peut-on traiter une appendicite aiguë par des antibiotiques et dans quelles conditions ? ACTA ACUST UNITED AC 2009; 146 Spec No 1:17-21. [PMID: 19846094 DOI: 10.1016/j.jchir.2009.08.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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