Effect of prophylactic antibiotics in acute nonperforated appendicitis: a prospective, randomized, double-blind clinical study

Scientific evidence of the duration of antibiotic treatment in intra-abdominal infections with surgical focus control

A non-systematic review of the published scientific evidence has been carried out on the duration of empirical antibiotic treatment in surgical intra-abdominal infections (IIA) with effective focus control. Given the progressive increase in antibiotic resistance, it is urgent to have strategies to reduce the pressure on the microbiota. The American guidelines made by Mazuski et al. of 2017¹, as the central axis in the recommendations of the duration of empirical antibiotic treatment in intra-abdominal infections with control of the focus and a bibliographic search of all the articles that contained the keywords in Pubmed and Google Scholar is added. 21 articles referring to the duration of empirical antibiotic treatment in intra-abdominal infection with control of the focus are collected. With the American guidelines and these articles, a proposal is prepared for the duration of empirical antibiotic treatment in patients without risk factors between 24 and 72 h. And in those who present risk factors, it should be individualized with active monitoring every 24 h of fever, paralytic ileus and leukocytosis (FIL), before an early detection of complications or the need for changes in antibiotic treatment. Short treatments are just as effective as those of longer durations and are associated with fewer adverse effects, therefore, daily adjusting and reassessing the duration of empirical antibiotic treatment is essential for better practice.

Surgical site infection and timing of prophylactic antibiotics for appendectomy

BACKGROUND

Pre-operative prophylactic antibiotics may decrease the frequency of surgical site infection after appendectomy. However, the optimal timing for administration of pre-operative prophylactic antibiotics is unknown. The purpose of this study was to evaluate the effect of timing of prophylactic antibiotics on the frequency of surgical site infection after appendectomy.

METHODS

Medical records were reviewed retrospectively for 577 consecutive patients who had appendectomy for acute appendicitis from 2006 to 2009. Quality assurance guidelines for timing of prophylactic antibiotics before the skin incision were changed from 0 to 30 min before the skin incision (before June 2008) to 30 to 60 min before the skin incision (after June 2008).

RESULTS

Surgical site infection occurred in 28 patients (4.9%). There was no difference in frequency of surgical site infection with different timing of pre-operative prophylactic antibiotic (pre-operative time 0 to 30 min: 9 infections [3.6%]; 31 to 60 min: 13 infections [5.4%]; 61 to 120 min: 5 infections [7.0%]; >120 min: 1 infection [6.6%]). Multivariable analysis showed that surgical site infection was associated significantly with medical comorbidity but not perforated appendicitis.

CONCLUSIONS

The frequency of surgical site infection was independent of timing of preoperative prophylactic antibiotics but was associated with the presence of medical comorbidity.

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.

Oral metronidazole as antibiotic prophylaxis for patients with nonperforated appendicitis

Background

The rate of wound infection after appendectomy without antibiotic prophylaxis is 10%–30%. The role of prophylactic antibiotic therapy in nonperforated appendicitis is still controversial. Metronidazole is against anaerobic organisms and its bioavailability after oral and parenteral administration has been shown to be similar. The objective of the present study is to compare the infective complications rate after open appendectomy for nonperforated appendicitis receiving either oral or intravenous metronidazole as prophylaxis.

Methods and Materials

From June 2007 to July 2009 in a randomized controlled trial, 204 patients with nonperforated appendicitis underwent an open appendectomy; 122 male and 82 female with mean age of 25 years. Among these, 102 (case group) received oral metronidazole and in 102 (control group) metronidazole was administered intravenously before surgery. The rate of wound infection and duration of the postoperative hospital stay was studied in the two groups.

Results

The rate of wound infection was not significantly different in the two groups. (6% and 4% in study and control group, respectively, P = 0.861). Also the hospital stay was equal in two groups (2.3 days and 2.7 days in study and control group, respectively, P = 0.293).

Conclusion

Single dose of oral metronidazole prior to operation can provide a sufficient prophylaxis for nonperforated appendicitis; so, it can be substitute the parental route of antibiotic administration.

Postoperative antibiotics correlate with worse outcomes after appendectomy for nonperforated appendicitis

BACKGROUND

Acute appendicitis remains the most common cause of acute abdominal pain necessitating operative intervention. Although postoperative antibiotics are universally used for perforated appendicitis, no consensus exists on whether postoperative antibiotics are beneficial for preventing surgical site infections (SSIs) in nonperforated cases. We set out to determine how postoperative antibiotic therapy affects outcomes after appendectomy for nonperforated appendicitis.

STUDY DESIGN

The medical records of 1,000 patients undergoing appendectomy for nonperforated appendicitis at The Mount Sinai Medical Center from January 2005 through July 2010 were retrospectively reviewed.

RESULTS

In total, 728 cases contained sufficient follow-up data for analysis; 334 of these patients received postoperative antibiotics and 394 did not. There were no significant differences in patient demographics, medical comorbidities, American Society of Anesthesiologists (ASA) class, admission temperature, preoperative antibiotic treatment, operating room time, estimated blood loss, appendiceal diameter, or intraoperative transfusion between the two groups, although WBC was higher for patients receiving postoperative antibiotics (12.3 vs 14 cells/mm(3), p = 0.001). Postoperative antibiotics did not alter the incidence of superficial SSIs, deep SSIs, or organ space SSIs (all p = 0.1), but did correlate with higher rates of Clostridium difficile infection (p = 0.02), urinary tract infection (p = 0.05), postoperative diarrhea (p < 0.001), and longer length of stay (LOS) (1.1 vs 2.4 days, p < 0.001). Patients receiving postoperative antibiotics also showed trends toward higher readmission and reoperation rates (both p = 0.06).

CONCLUSIONS

Postoperative antibiotic treatment for nonperforated appendicitis did not reduce infectious complications and prolonged LOS while increasing postoperative morbidity. Therefore, postoperative antibiotics likely increase the treatment cost for nonperforated appendicitis while not adding an appreciable clinical benefit and, in some cases, actually worsening outcomes.

Port site necrotising fasciitis following laparoscopic appendicectomy

Necrotising fasciitis is a fast-spreading infection affecting the fascia and, with continued spread, causes secondary necrosis of the skin. A case has been previously described in association with laparoscopic appendicectomy but with a fatal outcome. We report a similar but successfully managed case and review the literature.

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.

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).

Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis

BACKGROUND

The effect of extended prophylactic antibiotic therapy on postoperative infective complications such as wound infection and intra-abdominal abscess for non-perforated appendicitis is poorly defined.

METHODS

In a randomized controlled trial of 269 patients aged 15-70 years with non-perforated appendicitis undergoing open appendicectomy; 92 received single dose preoperative (group A), 94 received three-dose (group B) and 83 received 5-day perioperative (group C) regimens of cefuroxime and metronidazole. Postoperative infective complication was the primary endpoint. Secondary outcomes included length of hospital stay and complications related to antibiotic therapy.

RESULTS

The rate of postoperative infective complication was not significantly different among the groups (6.5% group A, 6.4% group B, 3.6% group C). The duration of antibiotic therapy had no significant effect on the length of hospital stay. Complications related to antibiotic treatment were significantly more common for 5-day perioperative antibiotic group (C) compared with single dose preoperative antibiotic group (A) (P = 0.048).

CONCLUSION

Single dose of preoperative antibiotics is adequate for prevention of postoperative infective complications in patients with non-perforated appendicitis undergoing open appendicectomy. Prolonging the use of antibiotics can lead to unnecessary antibiotic related complications.

Antibiotics versus placebo for prevention of postoperative infection after appendicectomy

BACKGROUND

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. The cause of appendicitis is unclear and the mechanism of pathogenesis continues to be debated. Despite improved asepsis and surgical techniques, postoperative complications, such as wound infection and intraabdominal abscess, still account for a significant morbidity. Several studies implicate that postoperative infections are reduced by administration of antimicrobial regimes.

OBJECTIVES

This review evaluated the use of antibiotics compared to placebo or no treatment in patients undergoing appendectomy. Will these patients benefit from antimicrobial prophylaxis? The outcomes were described according to the nature of the appendix, as either simple appendicitis (including the non-infectious stage) and complicated appendicitis. The efficacy of different antibiotic regimens were not evaluated.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (Cochrane Library 2005 issue 1); Pubmed ; EMBASE; and the Cochrane Colorectal Cancer Group Specialised Register (April 2005). In addition, we manually searched the reference lists of the primary identified trials.

SELECTION CRITERIA

We evaluated Randomised Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs) in which any antibiotic regime were compared to placebo in patients suspected of having appendicitis, and undergoing appendectomy. Both studies on children and adults were reviewed. The outcome measures of the studies were: Wound infection, intra abdominal abscess, length of stay in hospital, and mortality.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed, recorded and cross-checked by two reviewers.

MAIN RESULTS

Forty-five studies including 9576 patients were included in this review. The overall result is that the use of antibiotics is superior to placebo for preventing wound infection and intraabdominal abscess, with no apparent difference in the nature of the removed appendix. Studies exclusively on children and studies examining topical application reported results in favour to the above, although the results were not significant.

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis is effective in the prevention of postoperative complications in appendectomised patients, whether the administration is given pre-, peri- or post-operatively, and could be considered for routine in emergency appendectomies.

Is it justified to obtain routine peritoneal fluid cultures during appendectomy in children?

Controversy exists regarding obtaining routine peritoneal cultures during appendectomy. The aim of the study was to determine the impact of obtaining routine peritoneal fluid cultures during appendectomy on the treatment and clinical outcome in children. The charts of 269 children who were operated with the diagnosis of appendicitis between January 1996 and January 2001 were reviewed. The microorganisms in peritoneal cultures, selection of antibiotics and clinical outcome were evaluated. Average age was 10.1+/-3.3 (range, 1 to 17 years) years with a male to female ratio of 1.7 (170/99). There were two groups of patients; Group 1: uncomplicated appendicitis (201/269=75%), and Group 2: complicated (perforated) appendicitis (49/269=18%). In the series, 19 patients were found to have a normal appendix in histopathological examination (7%). Cultures were obtained from 95 (35.3%) patients (group 1: 59/95, group 2: 36/95). In patients with uncomplicated appendicitis, 6.7% of the cultures (4/59) were positive while in group 2, the rate was 47.2% (17/36) ( p<0.05). Only in four patients who were in group 2, antibiotics were re-adjusted according to the cultures. Escherichia coli and Klebsiella pneumoniae were the most common microorganisms. There were no complications in group 1, while wound infection (18.3%) and intra-abdominal abscess (2%) were the two most common complications in group 2. Intra-operative peritoneal cultures during appendectomy do not add much to the treatment of children. Therefore, it is not necessary to get peritoneal swab cultures during the procedures, and empiric use of wide spectrum antibiotics when necessary is generally sufficient in the management of this group of children.

Antibiotics versus placebo for prevention of postoperative infection after appendicectomy

BACKGROUND

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. The cause of appendicitis is unclear and the mechanism of pathogenesis continues to be debated. Despite improved asepsis and surgical techniques, postoperative complications, such as wound infection and intraabdominal abscess, still account for a significant morbidity. Several studies implicate that postoperative infections are reduced by administration of antimicrobial regimes.

OBJECTIVES

The objective of this review is to evaluate the use of antibiotics with placebo or no treatment in patients undergoing appendectomy. Will these patients benefit from antimicrobial prophylaxis? The outcomes are described according to the nature of the appendix, as either simple appendicitis (including the non-infectious stage) and complicated appendicitis. This review do not attempt to compare the effect of different regimens. That clinical question is addressed in another review undertaken by Bleuer 1999.

SEARCH STRATEGY

We searched The Cochrane Controlled Trials Register (Cochrane Library 2002 issue 4); Pubmed, Embase and the Cochrane Colorectal Cancer Group Specialised Register (Up to October 2002). In addition we manually searched the reference lists of the primary identified trials.

SELECTION CRITERIA

We evaluated Randomised Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs) in which any antibiotic regime were compared to placebo in patients suspected of having appendicitis, and undergoing appendectomy. Both studies on children and adults were reviewed. The outcome measures of the studies were: Wound infection, intra abdominal abscess, length of stay in hospital, and mortality.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed, recorded and cross-checked by two reviewers.

MAIN RESULTS

Forty-five studies including 9576 patients were included in this review. The overall result is that the use of antibiotics is superior to placebo for preventing wound infection and intraabdominal abscess, with no apparent difference in the nature of the removed appendix. Studies exclusively on children and studies examining topical application reported results in favour to the above although the results were not significant.

REVIEWER'S CONCLUSIONS

Antibiotic prophylaxis is effective in the prevention of postoperative complications in appendectomised patients, whether the administration is given pre-, peri- or post-operatively, and could be considered for routine in emergency appendectomies.

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.

Topical ampicillin for prophylaxis against wound infection in acute appendicitis

A total of 249 patients, undergoing appendectomy for acute appendicitis, were prospectively randomized into two groups. Group I, comprising 132 patients, received sterile normal saline irrigation to the surgical wound at closure. Alternatively, Group II included 117 patients, who received intraoperative topical ampicillin irrigation of the wound. Both groups were comparable with regard to age, sex, duration of symptoms, and severity of appendicitis. All patients additionally received preoperative systemic gentamicin and Flagyl. Wound infection occurred in 5.3% of Group I compared to only 0.9% of Group II (P<0.05). The reduction in infection rate was significant (P<0.05) in histologically proven appendicitis. We conclude that the addition of intraoperative topical ampicillin to systemic gentamicin and Flagyl augments prophylaxis against wound infection in acute appendicitis.

[Antibiotic prophylaxis and appendectomy]

Analysis of clinical studies shows that a single preoperative systematic administration of antibiotics may reduce postoperative sepsis rate after appendicectomy. If the appendix is gangrenous or perforated, this therapy must last for a longer time and is not considered as a prophylaxis. In clinical practice, there are obvious advantages in the use of a single agent efficient against both aerobes and anaerobes. According to the literature, cefotetan or cefoxitin (2 g in adults, 40 mg.kg-1 in children) can be proposed.

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)

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.

Combined topical and systemic antibiotic prophylaxis in acute appendicitis

Two hundred forty-six patients with acute appendicitis were randomly assigned to one of two groups. One group of 120 patients received systemic clindamycin preoperatively. Another group of 126 patients received, in addition to systemic clindamycin, a solution of topical ampicillin applied to subcutaneous tissues. No differences were found in the characteristics of the two groups. Combined prophylaxis with clindamycin and ampicillin significantly reduced wound infection to 4%, compared with clindamycin alone (p less than 0.02). A decrease in the surgical wound infection rate in the group treated with clindamycin and ampicillin was mainly observed in patients with advanced (gangrenous and perforated) appendicitis (p less than 0.05). A significant decrease in wound infection rates in patients with positive culture results was also found. We conclude that prophylaxis with a combination of systemic clindamycin and topical ampicillin solution, when compared with clindamycin alone, more effectively prevents wound infection after emergency appendectomy, especially in patients with serious wound contamination.

Antibiotic prophylaxis in acute nonperforated appendicitis. The Danish Multicenter Study Group III

In a prospective, block-randomized, multicenter study, the safety and efficacy of cefoxitin in preoperative prophylaxis were studied. 1735 patients undergoing appendectomy were evaluable, and half of these patients received 2 g of cefoxitin before undergoing operation. The patients were divided into three groups: patients with a normal appendix, patients with an acutely inflamed appendix, and patients with a gangrenous appendix. The study showed for each group a significant reduction of the incidence of wound infection in patients receiving prophylaxis. However, intra-abdominal abscess formation was not influenced by preoperative antibiotic prophylaxis. Consequently, routine preoperative prophylaxis is recommended before appendectomy.

Back to basics

The Society for Surgery of the Alimentary Tract originated as the Society for Colon Surgery. Therefore, it is appropriate that the dramatic developments in colorectal surgery that have occurred during the life of the Society should be emphasized. Major technical advances are identified as ileoanal anastomoses, colonoscopy, and EEA staplers. Although control of cancer remains a major problem, recent trends in the education and agenda of colorectal surgeons promise a bright future.

Preventing wound infection after appendicectomy: a review

An exponential increase in the number of published prospective studies reflects both a continuing interest in, and a lack of consensus on, the optimal prophylaxis of wound sepsis after appendicectomy. Review of the literature over the last 25 years leads us to emphasize both the importance of adequate study size and of stratification of the severity of the sepsis found at operation. For critical comparison of prophylactic regimens the high percentage of wound infections disclosed after discharge from hospital must be taken into account. Antibiotics reduce the frequency of wound sepsis and although low wound sepsis rates have been reported with systemic antibiotics active against only anaerobes, the cumulative evidence favours a spectrum of antibacterial activity against both aerobic and anaerobic organisms. Topical antiseptics have no significant effect but topical antibiotics are beneficial. Wide variations in outcome for similar antibiotic regimens reflect the importance of technical factors in determining the frequency of wound sepsis.

Antibiotic prophylaxis in non-perforated appendicitis of childhood: tetracycline lavage compared with peroperative intravenous cefuroxime and metronidazole

Eighty-four cases of non-perforated appendicitis in children were randomly allocated to receive either oxytetracycline lavage alone or oxytetracycline lavage plus peroperative intravenous metronidazole and cefuroxime. The wound infection rate with the oxytetracycline lavage alone was 4.4% compared with 7.7% when metronidazole and cefuroxime were added. These rates were not significantly different. This study supports the use of oxytetracycline lavage alone as effective prophylaxis against wound infection in non-perforated appendicitis of childhood.

Cephalosporins in surgery. Prophylaxis and therapy

Prophylactic antibiotics in surgery are intended to prevent morbidity and mortality, as well as to reduce the duration and cost of hospitalisation. The indications for prophylaxis, and its effectiveness, should be evaluated with these criteria in mind. The basis for antibiotic prophylaxis in surgery is either provision of an effective concentration of antibiotic in the tissue site at the time of potential contamination, or (primarily in the case of colorectal surgery) to reduce the inoculum of potentially contaminating bacteria. Cephalosporins are the antibiotics most widely used for prophylaxis in surgery, and have clearly been shown to reduce postoperative morbidity in vaginal hysterectomy, resection of head and neck cancers, vascular grafting, total joint replacement, repair of hip fractures, and high risk gastroduodenal surgery. They are probably also useful in cardiac surgery, abdominal hysterectomy, caesarean section, and colorectal surgery. For orthopaedic, cardiac, gynaecological, and gastroduodenal procedures it is important to select an antibiotic with proven clinical activity against Gram-positive organisms. For head and neck surgery, the spectrum of activity should also include oral anaerobes and Enterobacteriaceae. For biliary surgery an antibiotic effective against both Gram-positive and Gram-negative organisms may offer at least theoretical advantages, while for appendicectomy a cephamycin represents the most appropriate choice. In colorectal procedures, activity against B. fragilis is the major consideration in selecting an antibiotic for systemic prophylaxis. When intra-abdominal sepsis occurs following surgery, a potentially wide range of bacteria may be implicated, but in practice such infections are due to a small number of species, with B. fragilis most commonly implicated. The most useful cephalosporins in this setting are those active against both aerobic Gram-negative bacteria and anaerobes, especially B. fragilis. In practice, an aminoglycoside is often administered concomitantly. Importantly, prompt surgical treatment is the cornerstone of management of abdominal sepsis, and empirical antibiotic therapy should be adjusted as needed when culture and sensitivity tests become available.

The avoidable excesses in the management of perforated appendicitis in children

During a five-year period from 1979 to 1985, 100 consecutive children with perforated appendicitis were managed at our institution. These patients were divided into two groups, which were determined by length of illness and physical findings. Group A consisted of 88 children with signs and symptoms of peritonitis from appendiceal perforation. They were treated with fluid resuscitation, antipyretics, and triple antibiotics (ampicillin, gentamicin, clindamycin), and appendectomy within a few hours of hospitalization. Saline lavage was used. Group B was composed of 12 patients with a periappendiceal mass without generalized peritonitis who had symptoms of 6 to 12 days duration. They were treated nonoperatively with triple antibiotics and underwent interval appendectomy 4 to 6 weeks later. The complication rate for Group A was 6.8%. This included three wound infections (3.4%), one intra-abdominal abscess (1.1%), one patient with pneumonia and ileus (1.1%), and a small bowel obstruction (1.1%). These results are equivalent to the lowest complication rate reported in the literature, in which the treatment included transperitoneal drainage, antibiotic lavage, and parenteral antibiotics. Group B patients had a 16.7% complication rate, which included one small bowel obstruction and one recurrent intra-abdominal abscess. Our method of management resulted in the lowest complication rate reported to date in children with perforated appendicitis. Transperitoneal drainage, delayed wound closure, and antibiotic lavage were not used. Subcuticular incisional closure resulted in minimal wound care and excellent cosmetic results. The experience demonstrates that with proper timing of surgery and appropriate use of contemporary antibiotics, the morbidity of perforated appendicitis can be limited and excesses of treatment can be avoided.

Selected overview of nongynecologic surgical intra-abdominal infections. Prophylaxis and therapy

True prophylaxis of intra-abdominal nongynecologic infections is limited to elective, nonemergency surgery and is best shown in three clean-contaminated surgical procedures. All of these have an infection rate of approximately 10 to 20 percent and include all colon resection surgery, most gastric surgery, and about one third of the cholecystectomies for chronic calculous cholecystitis. Each of these three surgical procedures has a somewhat different pattern of bacterial pathogens. The most useful comparative studies of early preoperative therapy have been performed in cases of suspected appendicitis (50 percent of which usually show perforation or gangrene at the time of surgery) and penetrating abdominal wounds (80 percent of which usually enter some part of the bowel and theoretically soil the peritoneum). These procedures are usually classified as contaminated, with a 20 to 30 percent infection rate, or dirty, with a more than 30 percent infection rate, depending upon several factors. Comparative investigations of intraoperative and postoperative antibiotic therapy of established intra-abdominal infections are more difficult to obtain because of the heterogeneity of the sites, organisms, and medical and surgical therapy. The initial pathogens causing secondary peritonitis and hepatic, perirectal, diverticular, and most other types of intraperitoneal abscesses are mixed coliforms and anaerobes, with emphasis on the anaerobes. Retroperitoneal abscesses, pancreatic abscesses, and biliary tract infections are predominantly caused by coliforms. The organisms responsible for these early infections are usually community-acquired rather than more antibiotic-resistant hospital-acquired bacteria. Considering the availability of a large number of effective broad-spectrum antibacterial agents and therapeutic combinations, it has become increasingly difficult to assess the rightful place of any new prospective antimicrobial regimen unless it has quite unique characteristics. Most empiric therapy in established intra-abdominal infection studies have compared gentamicin and clindamycin, the most popular regimen in the United States over the past 15 years, with a cephalosporin, broad-spectrum penicillin, or aminoglycoside, either alone or together with clindamycin or metronidazole. Results have usually been considered similar in most studies, although in some studies, agents with limited Bacteroides fragilis activity, such as cefamandole or cefaperazone, have been considered inferior. Most new prophylactic regimens have been compared with the first-generation cephalosporins and, again, similar results have been obtained between the groups with two exceptions. Cepha

Randomized, prospective, and double-blind trial of new beta-lactams in the treatment of appendicitis

A prospective, randomized, and double-blind study was conducted with 864 patients operated on for appendicitis. In early cases, including normal and acute appendicitis, one dose of antibiotic was given. The rate of postappendectomy septic complications in patients who received cefotaxime, cefoperazone, or moxalactam was very low (about 3%), and there was no statistical difference between the drugs. For late cases, including gangrenous and perforated appendicitis, the antibiotics were continued for 5 days. Moxalactam decreased significantly the septic complications in these patients when compared with the other two drugs. It is safe, free from serious toxic side effects, and more convenient and easier to administer than combination antibiotic therapy. The main disadvantage of moxalactam is its high cost, but this has to be balanced against the savings in nursing time, the cost of monitoring renal function and serum level when aminoglycosides are used, and the reduced usage and manipulation of infusion sets.

Abdominal pain unrelated to trauma

This article reviews the more common causes of abdominal pain in children. It is divided into three sections to emphasize differential diagnosis. For some problems responsible for abdominal pain surgery is essential, for some surgery may not be initially required but may be unavoidable, and for others the condition is purely medical and surgery should be avoided. Armed with a complete differential diagnosis, the general surgical resident may avoid many pitfalls.

Prophylactic antibiotics in appendicectomy: a prospective double blind randomized study

Our double blind prospective randomized trial comparing intravenous cefoxitin with rectal metronidazole in appendicectomy reveals both groups to be similar regarding basic data, with no significant difference in the results between the two drugs. Nearly all the wound infections occurred after the patient went home. Most were minor infections and the overall infection rate was 6%. The intravenous route was the more certain but the more expensive. Bacteriology suggests that the same flora were present in the appendiceal wall of normal and acute non-perforated appendices. This would suggest bacteriologically that the same risks exist with non-inflamed appendicectomy as occurs with inflamed non-perforated appendices. These findings support the use of short course prophylaxis in appendicectomy.

Appendicitis near its centenary

In an analysis of the first 72 cases treated after the formulation of the appendicitis syndrome in 1886 compared with the experience from 1929-1959 and with 307 randomly selected recent cases, the major therapeutic trend has been an emphasis on appendectomy before perforation and abscess formation occur. The rate of infection nonetheless remains approximately 17%. Although the overall mortality rate has declined from 26% overall (40% for surgery) to 0.8%, the current rate of perforation is 28%, with a diagnostic accuracy of 82%. Among 13,848 patients from several reports the perforation rate increases linearly with diagnostic accuracy; therefore, a balance must be sought. Delay awaiting a diagnosis is a major determinant of perforation, but diagnostic aids are of limited help. Clinical acuity and prudent decisiveness are the keys to proper action.

The bacteriology and septic complication of patients with appendicitis

A detailed bacteriologic study was done on 161 patients operated for appendicitis. Aerobic and anaerobic cultures were taken from the blood, the appendicular lumen, mucosa, serosa, fossa, and from the wound after closure of the peritoneum. There is no correlation between the degree of appendicitis and the incidence of positive blood culture. The infection spread through the appendicular wall as the disease progressed. Aerobic infection was common in early appendicitis but a mixed aerobic and anaerobic infection was predominant in late cases. Late appendicitis, a positive wound culture at the end of the operation, the duration of symptoms of over 36 hours before operation and the age of the patient over 50 years were all associated with an increased incidence of septic complication. From the antibiotic sensitivity on the bacteria isolated, the most effective agent against anaerobes was metronidazole. Effective agents against the aerobes were aminoglycosides and cephalosporins. The best single agent against both anaerobes and aerobes was moxalactum.

Surgical antimicrobial prophylaxis: principles and guidelines

Antimicrobial prophylaxis for surgical procedures is an area that is recognized as being subject to individual clinical variations. This review gives practitioners some basic principles of rational prophylaxis as defined by the medical literature. In addition, this literature is evaluated and condensed to provide clinicians with guidelines for particular procedures: obstetric, gynecologic, gastric, biliary, colonic, urologic, cardiac, thoracic, vascular, orthopedic and head and neck. Each section concludes with recommendations for the clinically most accepted prophylactic regimens. Antibiotics discussed include not only the older agents, but where good information exists, the newer cephalosporins. The suggested regimens consider efficacy, safety and cost as determinants in rational prescribing. Although research into even shorter, and perhaps more cost-effective, regimens continues, this compilation lists state-of-the-art recommendations.

Prophylaxis of post-appendicectomy sepsis by metronidazole and ampicillin: a randomized, prospective and double-blind trial

Two hundred and eighty-three patients were admitted to a randomized, prospective and double-blind trial of the effect of the addition of ampicillin to metronidazole in the prophylaxis of post-appendicectomy wound sepsis. Nineteen out of 142 patients in the metronidazole and ampicillin group developed wound sepsis compared with 33 out of 141 patients in the metronidazole group. The difference is statistically significant. Early cases, including normal, acutely inflamed and gangrenous appendices, received 2 doses of antibiotics. In late cases with perforation and abscess formation, the antibiotics were continued for 1 week. The difference in wound infection in each of these 2 subgroups was also statistically significant. The commonest organisms isolated from the appendicular fossa and the infected wounds were Escherichia coli and Bacteroides fragilis.

The prophylactic use of antimicrobials in surgery

During the period August 1976 to June 1982, there were 98 reports of antimicrobial prophylaxis in human surgery that were judged unevaluable. Our review, coupled with that of Chodak and Plaut, identified studies of 126 antibiotic regimens that were considered evaluable and a total of 205 studies considered unevaluable. A decrease in infection rate in antibiotic-treated patients compared to non-antibiotic-treated patients was seen in 120 (95%) of the evaluable regimens. Ninety-nine (79%) of these 120 regimens produced statistically significant reductions in the infection rate (P less than .05, chi 2 analysis). The majority of the antibiotic regimens were tested in procedures that were classified as clean-contaminated. Of the regimens that yielded a statistically significant reduction in infection rate with antimicrobial therapy, in 66 (67%) the agents were used for 24 hours or less. Five regimens were identified in which a higher infection rate occurred in specific patient groups when prophylactic antibiotics were used, but the differences were not statistically significant. In the overwhelming majority of evaluable studies, antibiotics decreased the incidence of surgical infection compared with non-antibiotic groups. The available data also support the effectiveness of short prophylactic antibiotic courses of 24 hours' duration or less. The duration necessary for antibiotic prophylaxis was specifically tested in nine regimens. In all nine, a short course (less than 24 hours) of antibiotic prophylaxis was as effective as longer periods of therapy (24 hours to 5 days) in preventing infection.

Antibiotic management of surgically treated gangrenous or perforated appendicitis. Comparison of gentamicin and clindamycin versus cefamandole versus cefoperazone

A study of 130 adult patients with surgically treated gangrenous or perforated appendicitis was undertaken to evaluate the efficacy of three antibiotic regimens. Forty-eight patients received cefamandole, 40 were given the combination of clindamycin and gentamicin, and 42 were treated with cefoperazone. Side effects from these antibiotics were infrequent and mild. When all cases were compared for infectious failure, clindamycin-gentamicin showed a clear advantage over cefamandole. Because of the heterogeneity of the total study population, patients with perforation and peritonitis were compared separately. This analysis confirmed the advantage of clindamycin-gentamicin over cefamandole. In addition, it appears that clindamycin-gentamicin is more efficacious than cefoperazone.