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Keane OA, Motley T, Robinson J, Smith A, Short HL, Santore MT. Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative. J Pediatr Surg 2024; 59:1058-1065. [PMID: 38030531 DOI: 10.1016/j.jpedsurg.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative. METHODS On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation. RESULTS In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001). CONCLUSION Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care. STUDY TYPE Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Theresa Motley
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jenny Robinson
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Alexis Smith
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew T Santore
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Rossidis AC, Brown EG, Payton KJ, Mattei P. Implementation of an evidence-based protocol after appendectomy reduces unnecessary antibiotics. J Pediatr Surg 2020; 55:2379-2386. [PMID: 32753275 DOI: 10.1016/j.jpedsurg.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Children with acute appendicitis have historically received intravenous antibiotics before and after appendectomy, yet recent literature supports minimizing postoperative antibiotics. In this study, we examined the impact of a standardized protocol that eliminates postoperative antibiotics for nonperforated appendicitis and discontinues antibiotics at discharge for perforated appendicitis. METHODS A retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis between May 2013 and March 2017 was performed. Preprotocol patients (5/1/2013-3/31/2015) were compared to postprotocol patients (5/1/2015-3/31/2017), excluding those who underwent surgery during the month of protocol introduction (4/2015). Primary outcomes were postoperative antibiotic doses for nonperforated cases and antibiotics after discharge for perforated cases. Mann-Whitney and Fisher's exact tests were performed. RESULTS Laparoscopic appendectomy was performed in 748 children before (PRE) and in 814 children after (POST) protocol implementation. Perforation rates were similar (POST 21.5 vs. PRE 21.8%, p=0.90). For nonperforated appendicitis, postoperative antibiotics were reduced (median 0 [IQR 0-0] vs. 3 [0-5] doses, p<0.001), and more patients were discharged less than 24 h after surgery (65.7 vs. 40.9%, p<0.001). Fewer patients with perforated appendicitis underwent PICC placement (8.6 vs. 21.0%, p=0.002), and fewer patients were prescribed antibiotics on discharge (33.7 vs. 89.0%, p<0.001). There were no differences between groups for complication, readmission, or return to ED rates. CONCLUSION For children with acute appendicitis, a standardized protocol can safely reduce unnecessary antibiotics and decrease length of stay. Furthermore, the judicious use of antibiotics does not increase SSI, readmission, or overall complication rates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Avery C Rossidis
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Erin G Brown
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - K Joy Payton
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Peter Mattei
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
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Baumann LM, Williams K, Oyetunji TA, Grabowski J, Lautz TB. Optimal Timing of Postoperative Imaging for Complicated Appendicitis. J Laparoendosc Adv Surg Tech A 2018; 28:1248-1252. [PMID: 29870297 DOI: 10.1089/lap.2018.0121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Approximately one quarter of children with complicated appendicitis develop postoperative abscess, leading to additional procedures and increased length of stay (LOS), but the optimal timing of postoperative imaging to detect abscess is unknown. METHODS The Pediatric Health Information System database was reviewed, and children who underwent laparoscopic appendectomy in 2013-2014 with postoperative LOS ≥5 days were included. Demographics, imaging, drainage procedures, LOS, and 30-day readmission were analyzed. Chi-squared analysis was performed. RESULTS A total of 21,985 patients underwent laparoscopic appendectomy and 3332 met inclusion criteria. A total of 1174 (35.2%) patients underwent postoperative imaging, among whom 38.4% underwent ultrasound and 75.0% underwent computed tomography scan. Timing of first imaging varied significantly between hospitals, ranging from 0% to 76% on postoperative day (POD) 5. Initial imaging was performed on POD 5, 6, and 7 in 19.7%, 31.3%, and 36.2%, respectively. Imaging on POD 5 compared with POD 7 was associated with shorter LOS (10.6 ± 5.7 versus 11.8 ± 4.4 days), but also lower rates of intervention (42.4% versus 50.8%), increased repeat imaging (10.8% versus 5.2%), and higher readmission rates (35.9% versus 28.2%) (P < .05). CONCLUSION Timing of postoperative imaging for complicated appendicitis is variable across hospitals. While earlier imaging was associated with a decreased LOS, these children also had lower rates of subsequent intervention coupled with higher rates of repeat imaging and readmission. These findings suggest that delaying imaging until at least POD 6 may maximize the diagnostic yield of imaging while decreasing radiation exposure and readmission. Prospective investigation should be undertaken to guide the development of standardized clinical practice guidelines for the management of perforated appendicitis.
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Affiliation(s)
- Lauren M Baumann
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois.,2 Department of Surgery, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Kibileri Williams
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois.,2 Department of Surgery, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Tolulope A Oyetunji
- 3 Department of Surgery, Children's Mercy Kansas City , Kansas City, Missouri
| | - Julia Grabowski
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois
| | - Timothy B Lautz
- 1 Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital , Chicago, Illinois.,2 Department of Surgery, Northwestern University Feinberg School of Medicine , Chicago, Illinois
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Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified? Ann Surg 2017; 266:361-368. [PMID: 27429024 DOI: 10.1097/sla.0000000000001923] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge. BACKGROUND Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited. METHODS We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting. RESULTS In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05-2.88; risk difference: 4.0%, 95% CI 0.4-7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44-3.11; risk difference: 9.4%, 95% CI 4.7-14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%). CONCLUSIONS Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.
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McMullan BJ, Andresen D, Blyth CC, Avent ML, Bowen AC, Britton PN, Clark JE, Cooper CM, Curtis N, Goeman E, Hazelton B, Haeusler GM, Khatami A, Newcombe JP, Osowicki J, Palasanthiran P, Starr M, Lai T, Nourse C, Francis JR, Isaacs D, Bryant PA. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. THE LANCET. INFECTIOUS DISEASES 2016; 16:e139-52. [PMID: 27321363 DOI: 10.1016/s1473-3099(16)30024-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 03/04/2016] [Accepted: 03/29/2016] [Indexed: 12/22/2022]
Abstract
Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.
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Affiliation(s)
- Brendan J McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, NSW, Australia
| | - David Andresen
- Department of Infectious Diseases, Immunology, and HIV Medicine, St Vincent's Hospital, Darlinghurst, NSW, Australia; Sydney Medical School, University of Sydney, NSW, Australia
| | - Christopher C Blyth
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Subiaco, WA, Australia; School of Paediatrics and Child Health, University of Western Australia, WA, Australia; PathWest Laboratory Medicine, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Minyon L Avent
- The University of Queensland, UQ Centre for Clinical Research and School of Public Health, Herston, QLD, Australia
| | - Asha C Bowen
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Subiaco, WA, Australia; School of Paediatrics and Child Health, University of Western Australia, WA, Australia; Menzies School of Health Research, Darwin, NT, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Philip N Britton
- Department of Infectious Diseases & Microbiology, Children's Hospital at Westmead, Westmead, NSW, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia
| | - Julia E Clark
- Infection Management and Prevention Service, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Celia M Cooper
- Department of Microbiology and Infectious Diseases, SA Pathology, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Emma Goeman
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Briony Hazelton
- Sydney Medical School, University of Sydney, NSW, Australia; Department of Infectious Diseases, Princess Margaret Hospital for Children, Subiaco, WA, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Infection and Immunity, Monash Children's Hospital, Clayton, VIC, Australia
| | - Ameneh Khatami
- Department of Infectious Diseases & Microbiology, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - James P Newcombe
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Pamela Palasanthiran
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, NSW, Australia
| | - Mike Starr
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Tony Lai
- Department of Pharmacy, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Clare Nourse
- Infection Management and Prevention Service, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Joshua R Francis
- Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - David Isaacs
- Department of Infectious Diseases & Microbiology, Children's Hospital at Westmead, Westmead, NSW, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia
| | - Penelope A Bryant
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
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Skarda DE, Schall K, Rollins M, Andrews S, Olson J, Greene T, McFadden M, Thorell EA, Barnhart D, Meyers R, Scaife E. Response-based therapy for ruptured appendicitis reduces resource utilization. J Pediatr Surg 2014; 49:1726-9. [PMID: 25487470 DOI: 10.1016/j.jpedsurg.2014.09.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 09/05/2014] [Indexed: 11/15/2022]
Abstract
PURPOSE We examined the effectiveness of a postoperative ruptured appendicitis protocol that eliminated Pseudomonas coverage and based the duration of IV antibiotic treatment and length of hospital stay on the patient's clinical response. METHODS In our new protocol, IV antibiotics were administered until the patient met discharge criteria: adequate oral intake, pain control with oral medications, and afebrile for 24h. We collected data on all patients with ruptured appendicitis at our institution following protocol implementation (May 1, 2012, to April 30, 2013) and compared them to a control group. RESULTS 306 patients were treated (154 prior protocol, 152 new protocol). The new clinical response-based protocol led to a decrease in hospital stay from 134h (SD 66.1) to 94.5h (SD 61.7) (p<0.001) and total cost of care per patient also decreased from $13,610 (SD $6859) to $9870 (SD $5670) (p<0.001). CONCLUSION Our clinical response-based protocol for pediatric patients with ruptured appendicitis decreased LOS, cost, and IV antibiotics use without significant changes in adverse events.
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Affiliation(s)
- David E Skarda
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT.
| | - Kathy Schall
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Michael Rollins
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Seth Andrews
- Systems Improvement Primary Children's Hospital, Salt Lake City, UT
| | - Jared Olson
- Department of Pharmacology, Primary Children's Hospital, Salt Lake City, UT
| | - Tom Greene
- University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, UT
| | - Molly McFadden
- University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, UT
| | - Emily A Thorell
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases, Salt Lake City, UT
| | - Doug Barnhart
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Rebecka Meyers
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Eric Scaife
- Division of Pediatric Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
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Sulkowski JP, Asti L, Cooper JN, Kenney BD, Raval MV, Rangel SJ, Deans KJ, Minneci PC. Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis. J Surg Res 2014; 190:235-41. [PMID: 24721604 DOI: 10.1016/j.jss.2014.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 03/03/2014] [Accepted: 03/05/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC). METHODS Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000-2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score-matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness. RESULTS We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P<0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P<0.001), and have a reencounter (17.5% versus 11.4%, P<0.001) within 30 d of discharge. However, in the PSM cohort (n=4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio=3.95, 95% confidence interval: 1.45, 10.71). CONCLUSIONS After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.
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Affiliation(s)
- Jason P Sulkowski
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Lindsey Asti
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer N Cooper
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Brian D Kenney
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Mehul V Raval
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Shawn J Rangel
- Department of Surgery, Children's Hospital Boston, Boston, Massachusetts
| | - Katherine J Deans
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio; Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, Columbus, Ohio.
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Bansal V, Altermatt S, Nadal D, Berger C. Lack of benefit of preoperative antimicrobial prophylaxis in children with acute appendicitis: a prospective cohort study. Infection 2012; 40:635-41. [PMID: 22810888 DOI: 10.1007/s15010-012-0297-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 06/28/2012] [Indexed: 12/01/2022]
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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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Ponsky TA, Hafi M, Heiss K, Dinsmore J, Newman KD, Gilbert J. Interobserver variation in the assessment of appendiceal perforation. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S15-8. [PMID: 19371148 DOI: 10.1089/lap.2008.0095.supp] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Following an appendectomy, surgeons define appendicitis, for treatment and billing purposes, into one of four categories: normal appendix, acute appendicitis, gangrenous appendicitis, and perforated appendicitis. Treatment of appendicitis is predicated upon classification at the time of visual inspection. Further, this classification often plays a role in the assessment of hospital outcomes. The currently accepted classification system is based solely upon intraoperative surgeon opinion and not objective data. Inconsistent surgeon grading of the severity of appendicitis may have implications in both management and outcomes. OBJECTIVE The aim of this study was to assess the interobserver variation among surgeons in grading of the inflammatory severity of acute appendicitis as recognized on visual findings at operation. METHODS A cross-sectional study design. 110 surgeons, and surgical residents were randomly selected. Surgeons were shown images of intraoperative appendicitis and were asked to evaluate the severity of the appendicitis (i.e., normal, inflamed, gangrenous, and perforated). Demographic information regarding the type of practice, hospital setting, and the number of encounters with patients with acute appendicitis were assessed. An Intraclass Correlation Coefficient score, represented by R, was calculated to assess interobserver reliability in grading the inflammatory severity of acute appendicitis. The two-way analysis of variance procedure for multivariate analysis was used for this calculation. RESULTS The study group consisted of 100 surgeons, 62 practicing surgeons, and 48 surgical trainees. Overall, 79% of the surgeons treated predominantly adults with appendicitis, 18% treated primarily children, and 3% treated both children and adults. Hospital practices included university hospitals (47%), community hospitals (33%), children's hospitals (14%), and others (6%). Overall, there was poor agreement among surgeons in assessing the severity of appendicitis. Among all attending surgeons, the agreement of defining an image as to whether it was perforated or not was 27% (R4 = 0.27). Completion of a general surgery residency did improve the interobserver agreement, when compared with trainees. CONCLUSION There is poor agreement among surgeons in describing the severity of appendicitis. Treatment protocols based on more accurate assessment and categorization could potentially lead to more favorable, cost-effective outcomes. Further, studies determining efficacy in the diagnosis and treatment of appendicitis should consider observer variability. Future work must attempt to define critical objective assessment points, such as visible discontinuity of the appendix or fecal soilage, to assure a better correlation of findings with prognosis.
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Affiliation(s)
- Todd A Ponsky
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio 44106, USA.
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Nadler EP, Gaines BA. The Surgical Infection Society Guidelines on Antimicrobial Therapy for Children with Appendicitis. Surg Infect (Larchmt) 2008; 9:75-83. [DOI: 10.1089/sur.2007.072] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Evan P. Nadler
- Division of Pediatric Surgery and Department of Surgery, New York University School of Medicine, New York, New York
| | - Barbara A. Gaines
- Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Abstract
Appendicitis is the most common surgical disease of the abdomen in children. Pediatric appendicitis varies considerably in its clinical presentation, contributing to delay in diagnosis and increased morbidity. The methods of diagnosis and treatment of appendicitis also vary significantly among clinicians and medical centers according to the patient's clinical status, the medical center's capabilities, and the physician's experience and technical expertise. Recent trends include the increased use of radiologic imaging, minimally invasive and nonoperative treatments, shorter hospital stays, and home antibiotic therapy. Little consensus exists regarding many aspects of the care of the child with complicated appendicitis. This article examines the most debated aspects of the diagnosis and management of the diseased pediatric appendix.
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Affiliation(s)
- Stephen E Morrow
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA.
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Emil S, Taylor M, Ndiforchu F, Nguyen N. What are the True Advantages of a Pediatric Appendicitis Clinical Pathway? Am Surg 2006. [DOI: 10.1177/000313480607201009] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Multiple protocols have been described for pediatric appendicitis, but few have been compared with off-protocol treatment. We performed such a comparison. Children treated for appendicitis by three pediatric surgeons over a 28-month period were studied. A protocol of primary wound closure without drains, standardized use of antibiotics, and patient discharge according to predetermined clinical criteria was compared with individualized drain use, antibiotic selection, and discharge timing. Three hundred ninety-seven children were treated, 43 per cent on pathway (Group I) and 57 per cent off pathway (Group II). The two groups showed similar incidence of acute (45% vs 46%), complicated (50% vs 49%), and normal (5%) appendix. Among patients with simple appendicitis, Group I had less postoperative antibiotic use (16% vs 80% P < 0.001), shorter hospital stays (1.44 vs 1.89 days, P = 0.001), and decreased hospital charges ($9,289 vs $10,751, P = 0.001). Among patients with complicated appendicitis, Group I had less drain placement (4% vs 27%, P < 0.001), less use of discharge antibiotics (13% vs 39%, P < 0.001), and no readmission (0% vs 5%, P = 0.05). Infectious complications were similar between the two groups. A clinical pathway decreases the use of unnecessary antibiotics, hospital stay, and charges for simple appendicitis. It decreases the use of unnecessary drains, and eliminates readmissions after complicated appendicitis.
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Affiliation(s)
- Sherif Emil
- From the Division of Pediatric Surgery, Department of Surgery, University of California, Irvine Children's Hospital, Orange, California and Miller Children's Hospital, Long Beach, California
| | - Michael Taylor
- From the Division of Pediatric Surgery, Department of Surgery, University of California, Irvine Children's Hospital, Orange, California and Miller Children's Hospital, Long Beach, California
| | - Fombe Ndiforchu
- From the Division of Pediatric Surgery, Department of Surgery, University of California, Irvine Children's Hospital, Orange, California and Miller Children's Hospital, Long Beach, California
| | - Nam Nguyen
- From the Division of Pediatric Surgery, Department of Surgery, University of California, Irvine Children's Hospital, Orange, California and Miller Children's Hospital, Long Beach, California
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Voit SB, Todd JK, Nelson B, Nyquist AC. Electronic surveillance system for monitoring surgical antimicrobial prophylaxis. Pediatrics 2005; 116:1317-22. [PMID: 16322153 DOI: 10.1542/peds.2004-1969] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Antimicrobial surgical prophylaxis comprises one third of all antibiotic use in pediatric hospitals and 80% of all antibiotic use in surgery. Previous studies reported that antimicrobial surgical prophylaxis is often inconsistent with recommended guidelines. An electronic surveillance system was developed to measure antimicrobial utilization and to identify opportunities to improve and monitor the administration of antibiotics for surgical prophylaxis. METHODS A retrospective cohort study was conducted on patients with selected inpatient surgical procedures performed from May 1999 to April 2000 at 4 US children's hospitals. International Classification of Diseases, Ninth Revision surgical procedure codes were divided into clean or unclean categories, and an electronic surveillance system was designed using antibiotic and microbiologic culture utilization data to measure appropriate antimicrobial use associated with the surgical procedure. A medical chart review was conducted to validate the electronic system. RESULTS Ninety percent of cases were classified properly by the electronic surveillance system as confirmed by medical chart review. Surgical antibiotic prophylaxis was not in accordance with the American Academy of Pediatrics (AAP) guidelines for almost half of all procedures. Prolonged antimicrobial administration in clean surgical procedures was the most frequent deviation from guidelines. Statistical differences between the index hospital and the comparison hospitals reflect both over- and underutilization of surgical prophylaxis with significant opportunity to improve prophylaxis for all hospitals. CONCLUSIONS Antimicrobial surgical prophylaxis at the children's hospitals studied is not always consistent with published AAP guidelines. This electronic surveillance system provides a rapid, reproducible, and validated tool to measure easily the efforts to improve adherence to AAP surgical prophylaxis guidelines.
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Affiliation(s)
- Sara Bornstein Voit
- Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, Colorado, USA
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15
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Emil S, Laberge JM, Mikhail P, Baican L, Flageole H, Nguyen L, Shaw K. Appendicitis in children: a ten-year update of therapeutic recommendations. J Pediatr Surg 2003; 38:236-42. [PMID: 12596112 DOI: 10.1053/jpsu.2003.50052] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND/PURPOSE In 1990, the authors reported excellent outcomes using a standard protocol to treat pediatric appendicitis. This protocol has been simplified further and a large retrospective review was conducted to assess current outcomes. METHODS All patients treated for presumed appendicitis between April 1997 and December 1999 were reviewed. All patients received preoperative gentamicin and clindamycin. Patients with complicated appendicitis received postoperative ampicillin, gentamicin, and clindamycin or metronidazole. All wounds were closed primarily without drains. Patients with complicated appendicitis were discharged when their ileus resolved, they remained afebrile for 24 hours, and had a normal leukocyte count. RESULTS A total of 648 patients were reviewed. A total of 9.4% of appendices were pathologically normal, 55.6% were simple acute, 15.7% were gangrenous, and 19.3% were perforated. Hospital stay was 2.21 +/- 2.04 days for normal, 1.39 +/-.89 for simple acute, 2.97 +/- 1.25 for gangrenous, and 6.31 +/- 3.51 days for perforated appendices. There were no wound infections in patients with normal or simple acute appendices. Two minor intraabdominal infections (0.56%) occurred in patients with simple appendicitis. Patients with complicated appendicitis (gangrenous or perforated) had wound infection and intraabdominal infection rates of 2.6% and 4.4%, respectively. CONCLUSIONS The authors' current protocol results in reasonable hospital stays and good outcomes. It serves as an evidence-based standard of care for the treatment of pediatric appendicitis.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric General Surgery, Department of Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Gollin G, Abarbanell A, Moores D. Oral Antibiotics in the Management of Perforated Appendicitis in Children. Am Surg 2002. [DOI: 10.1177/000313480206801209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
After appendectomy for perforated appendicitis children have traditionally been managed with intravenous broad-spectrum antibiotics for 5 to 10 days and then until fever and leukocytosis have resolved. We prospectively evaluated a protocol of hospital discharge on oral antibiotics when oral intake is tolerated—regardless of fever or leukocytosis—in a consecutive series of 80 children between one and 15 years of age who underwent appendectomy (38 open and 42 laparoscopic) for perforated appendicitis. At discharge subjects began a 7-day course of oral trimethoprim/sulfamethoxazole and metronidazole. Patients were discharged between 2 and 18 days postoperatively (mean 5.3 days). Sixty-six were discharged on oral antibiotics, and 28 of these had persistent fever or leukocytosis. Two patients (2.5%) developed postoperative intra-abdominal abscesses while inpatients. Wound infections developed in seven patients (8.8%) four of whom were on intravenous antibiotics. Among the 66 children who were discharged on oral antibiotics without having had an inpatient infectious complication there were three wound infections (4.4%). None of these patients had a fever or leukocytosis at discharge. We conclude that after appendectomy for perforated appendicitis children may be safely discharged home on oral antibiotics when enteral intake is tolerated regardless of fever or leukocytosis.
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Affiliation(s)
- Gerald Gollin
- Loma Linda University School of Medicine and Children's Hospital, Loma Linda, California
| | - Aaron Abarbanell
- Loma Linda University School of Medicine and Children's Hospital, Loma Linda, California
| | - Donald Moores
- Loma Linda University School of Medicine and Children's Hospital, Loma Linda, California
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Helmer KS, Robinson EK, Lally KP, Vasquez JC, Kwong KL, Liu TH, Mercer DW. Standardized patient care guidelines reduce infectious morbidity in appendectomy patients. Am J Surg 2002; 183:608-13. [PMID: 12095586 DOI: 10.1016/s0002-9610(02)00860-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Surgical wound infection and intra-abdominal abscess remain common infectious complications after appendectomy, especially in the setting of a perforated or gangrenous appendix. We therefore developed a clinical protocol for the management of appendicitis to decrease postoperative infectious complications. METHODS Between January 1, 1999, and December 31, 1999, 206 patients with appendicitis were treated on protocol. Retrospectively, the charts were reviewed for all protocol patients as well as for 232 patients with appendicitis treated in the year prior to protocol initiation. Data were collected on surgical wound infections and intra-abdominal abscesses. RESULTS There were significantly fewer infectious complications in the protocol group than in the nonprotocol group (20 [9%] versus 8 [4%]; P <0.05). In patients with a perforated or gangrenous appendix, the infectious complication rate was reduced from 33% to 13% (P <0.05). CONCLUSIONS The incidence of infectious complications after appendectomy can be significantly reduced with a standardized approach to antibiotic therapy and wound management.
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Affiliation(s)
- Kenneth S Helmer
- Department of Surgery, The University of Texas-Houston Medical School and LBJ General Hospital, 5656 Kelley St., Ste. 3-OS 62008, Houston, TX 77026, USA
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Bradley JS, Behrendt CE, Arrieta AC, Harrison CJ, Loeffler AM, Iaconis JP, Wald ER. Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis. Pediatr Infect Dis J 2001; 20:19-24. [PMID: 11176562 DOI: 10.1097/00006454-200101000-00005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with a perforated or gangrenous appendix become clinically stable after medical and/or surgical therapy but often remain in the hospital solely to complete parenteral antibiotic therapy. This prospective study investigates the outcomes when children who meet specified criteria are discharged to complete parenteral antibiotic therapy at home. METHODS Children age 1 to 17 years with appendicitis complicated by generalized peritonitis or intraabdominal abscess were eligible to participate. Subjects whose fever was decreasing, who were able to tolerate oral liquids and for whom further parenteral antibiotic therapy was deemed necessary were discharged from the hospital to receive outpatient parenteral antiinfective therapy (OPAT) with meropenem. Therapy was administered by a family member and supervised by home care nurses. Study personnel visited the home daily to collect data on adverse events, compliance and resource utilization. Pa tients served as their own controls in models of reduced hospitalization and net cost savings. RESULTS Discharged on average on the fourth postoperative day, 87 children received 4.5 +/- 2.1 days of OPAT. Six (7%) children were subsequently readmitted for complications including bowel obstruction (4 children), intraabdominal abscess (1 child) and pleural effusion (1 child). Another child developed a viral syndrome during OPAT. All other patients recovered uneventfully. Six (7%) children discontinued meropenem prematurely because of rash (4 patients) or diarrhea (2 patients). According to models in which each day of OPAT replaced a day of inpatient care, discharge to OPAT reduced hospitalization by 42 +/- 15% and saved a median of $2908 (10th to 90th percentile range, $1,077 to $4,707) per patient. CONCLUSION Convalescent phase OPAT is a cost-effective alternative to continued hospitalization for children with complicated appendicitis who are clinically stable yet require further parenteral antibiotic therapy.
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Affiliation(s)
- J S Bradley
- Division of Infectious Diseases, Children's Hospital, San Diego, CA, USA.
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