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Lipping E, Saar S, Reinsoo A, Bahhir A, Kirsimägi Ü, Lepner U, Talving P. Short Postoperative Intravenous Versus Oral Antibacterial Therapy in Complicated Acute Appendicitis: A Pilot Noninferiority Randomized Trial. Ann Surg 2024; 279:191-195. [PMID: 37747168 DOI: 10.1097/sla.0000000000006103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
OBJECTIVE The purpose of this study is to investigate noninferiority of postoperative oral administration of antibiotics in complicated appendicitis. BACKGROUND Recent investigations have used exclusively intravenous administration of antibiotics when comparing outcomes of postoperative antibacterial therapy in complicated appendicitis. We hypothesized that oral antibacterial treatment results in noninferior outcomes in terms of postoperative infectious complications as intravenous treatment. METHODS In this pilot, open-label, prospective randomized trial, all consecutive adult patients with complicated appendicitis, including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between November 2020 and January 2023, were randomly allocated to 24-hour intravenous administration of antibiotics versus 24-hour oral administration of antibiotics after appendectomy. Primary outcomes included 30-day postoperative complications per Comprehensive Complication Index. The secondary outcome was hospital length of stay. Follow-up analysis at 30 days was conducted per intention to treat and per protocol. The study was registered at ClinicalTrials.gov (NCT04947748). RESULTS A total of 104 patients were enrolled, with 51 and 53 cases allocated to the 24-hour intravenous and the 24-hour oral treatment group, respectively. Demographic profile and disease severity score for acute appendicitis were similar between the study groups. There were no significant differences between the study groups in terms of 30-day postoperative complications. Median Comprehensive Complication Index did not differ between the study groups. Hospital length of stay was similar in both groups. CONCLUSIONS In the current pilot randomized controlled trial, the 24-hour oral antibiotic administration resulted in noninferior outcomes when compared with the 24-hour intravenous administration of antibiotics after laparoscopic appendectomy in complicated appendicitis.
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Affiliation(s)
- Edgar Lipping
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Sten Saar
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Arvo Reinsoo
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Artjom Bahhir
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ülle Kirsimägi
- Faculty of Medicine, University of Tartu, Tartu, Estonia
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Urmas Lepner
- Faculty of Medicine, University of Tartu, Tartu, Estonia
- Department of Surgery, Tartu University Hospital, Tartu, Estonia
| | - Peep Talving
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
- Faculty of Medicine, University of Tartu, Tartu, Estonia
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Kroon HM, Kenyon-Smith T, Nair G, Virgin J, Thomas B, Juszczyk K, Hollington P. Safety and efficacy of short-course intravenous antibiotics after complicated appendicitis in selected patients. Acta Chir Belg 2023; 123:49-53. [PMID: 34120572 DOI: 10.1080/00015458.2021.1940726] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND After surgery for complicated appendicitis (CA), common practice is to treat all patients with a standardised long-course of intravenous antibiotics (IVAB) to reduce the risk of postoperative surgical infections (PSI). The aim of the current study was to evaluate the safety and efficacy of a short-course IVAB after CA in selected patients. METHODS The Department's prospectively collected database identified CA patients treated between2015 and 2019. Baseline and treatment characteristics and postoperative outcomes were analysed. The cut-off between short- and long-course IVAB was 2 days. Outcomes of interest were PSI and 30-day unplanned readmission. RESULTS In total, 226 patients had CA: Ninety-nine CA (43.8%) received short-course IVAB and 127 (56.2%) received long-course. PSI occurred in 6% and 10% of the short-course and long-course patients, respectively (p = 0.34). Length of IVAB after a PSI was comparable to that of patients without PSI (median 3 and 2 days of IVAB respectively; p = 0.28). 30-day unplanned readmission rates were 7% and 6%, respectively (p = 0.99). Length of IVAB for readmitted patients was similar to those who were not readmitted (median 3 days of IVAB in both; p = 0.91). Multivariable analysis showed that the intraoperative findings of the appendix (p = 0.04) was a prognostic predictor for PSI. ASA score (p = 0.02) and surgical approach (p = 0.05) were prognostic predictors for 30-day unplanned readmission. CONCLUSIONS This study shows that when patients respond well, a short-course IVAB can safely be applied after CA without increasing risk of PSI or 30-day unplanned readmission.
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Affiliation(s)
- Hidde M Kroon
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia.,Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Tim Kenyon-Smith
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Gavin Nair
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - James Virgin
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Bev Thomas
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Karolina Juszczyk
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Paul Hollington
- Colorectal Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
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de Jager E, Gunnarsson R, Ho YH. Self-discharge as a marker of surgical cultural competency and cultural safety for Aboriginal and/or Torres Strait Islander patients. ANZ J Surg 2022; 93:807-809. [PMID: 36582020 DOI: 10.1111/ans.18238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/15/2022] [Accepted: 12/18/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Elzerie de Jager
- College of Medicine and Dentistry, The James Cook University, Townsville, Queensland, Australia
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, the Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden.,Research, Education, Development & Innovation, Primary Health Care, Västra Götaland Region, Sweden.,Primary Health Care Center for Homeless People, Närhälsan, Västra Götaland Region, Sweden
| | - Yik-Hong Ho
- College of Medicine and Dentistry, The James Cook University, Townsville, Queensland, Australia.,Townsville Clinical School, The Townsville Hospital, Townsville, Queensland, Australia
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O'Brien P, Bunzli S, Lin I, Bessarab D, Coffin J, Dowsey MM, Choong PFM. Addressing surgical inequity for Aboriginal and Torres Strait Islander people in Australia's universal health care system: a call to action. ANZ J Surg 2021; 91:238-244. [PMID: 33506978 DOI: 10.1111/ans.16557] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/23/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022]
Abstract
Aboriginal and Torres Strait Islander people continue to experience health inequity within the Australian health care system. Little research has examined how disparities in surgical care access and outcomes contribute to Aboriginal health. In this narrative review and call to action, we discuss five care points along the journey to high-quality surgical care: health care seeking, primary health care services, specialist services, surgery and surgical outcomes. We highlight barriers and disparities that exist along this journey, drawing examples from the field of joint replacement surgery. Finally, we present opportunities for change at the health system, health service and clinician level, calling upon researchers, clinicians and policy makers to confront the surgical disparities experienced by Aboriginal and Torres Strait Islander people.
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Affiliation(s)
- Penny O'Brien
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | - Samantha Bunzli
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ivan Lin
- Western Australian Centre for Rural Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Dawn Bessarab
- Centre for Aboriginal Medical and Dental Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Juli Coffin
- Social and Emotional Wellbeing of Aboriginal Young People, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Michelle M Dowsey
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter F M Choong
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria, Australia
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Lawless RA, Cralley A, Qian S, Vasileiou G, Yeh DD. Antibiotics after Simple (Acute) Appendicitis are not Associated with Better Clinical Outcomes: A Post-Hoc Analysis of an EAST Multi-Center Study. Surg Infect (Larchmt) 2020; 22:504-508. [PMID: 32897168 DOI: 10.1089/sur.2019.348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The post-operative management of simple (acute) appendicitis differs throughout the United States. Guidelines regarding post-operative antibiotic usage remain unclear, and treatment generally is dictated by surgeon preference. We hypothesize that post-operative antibiotic use for simple appendicitis is not associated with lower post-operative complication rates. Methods: In a post-hoc analysis in a large multi-center observational study, only patients with an intra-operative diagnosis of AAST EGS Grade I were included. Subjects were classified into those receiving post-operative antibiotics (POST) and those given pre-operative antibiotics only (NONE). Clinical outcomes examined were length of stay (LOS), 30-day emergency department (ED) visits and hospital re-admissions, secondary interventions, surgical site infection (SSI), and intra-abdominal abscess (IAA). Results: A total of 2,191 subjects were included, of whom 612 (28%) received post-operative antibiotics. Compared with the NONE group, POST patients were older (age 37 [range 26-50] versus 33 [26-46] years; p < 0.001), weighed more (82 [70-96] versus 79 [68-93] kg (p = 0.038), and had higher white blood cell counts (13.5 ± 4.2 versus 13.1 ± 4.4/103/mcL (p = 0.046), Alvarado Scores (6 [5-7] versus 6 [5-7]; p < 0.001), and Charlson Comorbidity Indices (median score 0 in both cohorts; p < 0.001). The POST patients had a longer LOS (1 [1-2] versus 1 [1-1] days; p < 0.001). There were no differences in the number who had ED visits within 30 days (9% versus 8%; p = 0.435), hospital re-admission (4% versus 2%; p = 0.165), an index hospitalization SSI (0.2% for both cohorts; p = 0.69), an SSI within 30 days (4% versus 2%; p = 0.165), index hospitalization IAA rate (0.3% versus 0.1%; p = 0.190), 30-day IAA (2% versus 1%; p = 0.71), index hospitalization interventions (0.5% versus 0.1%; p = 0.137) or 30-day secondary interventions (2% versus 1%; p = 0.155). Conclusions: Post-operative antibiotic use after appendectomy for simple appendicitis is not associated with better post-operative clinical outcomes at index hospitalization or at 30 days after discharge.
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Affiliation(s)
| | | | - Sinong Qian
- Mayo Clinic Scottsdale, Scottsdale, Arizona, USA
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Truskett PG. Antimicrobial resistance and antibiotic usage: what can surgeons do? ANZ J Surg 2020; 90:198-199. [PMID: 32147914 DOI: 10.1111/ans.15741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Philip G Truskett
- Department of Surgery, Prince of Wales Clinical School, Sydney, New South Wales, Australia
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Jager E, Gunnarsson R, Ho Y. Measuring the quality of surgical care provision to Aboriginal and Torres Strait Islander patients. ANZ J Surg 2019; 89:1537-1538. [DOI: 10.1111/ans.15535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Elzerie Jager
- Center for Surgery and Public Health, Brigham and Women's HospitalHarvard Medical School Boston Massachusetts USA
- College of Medicine and DentistryJames Cook University Townsville Queensland Australia
| | - Ronny Gunnarsson
- Primary Health Care, Public Health and Community Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Region Vasta Gotland, Research and Development Primary Health CareResearch and Development Center Sodra Alvsborg Gothenburg Sweden
- Center for Antibiotic Resistance ResearchUniversity of Gothenburg Gothenburg Sweden
| | - Yik‐Hong Ho
- College of Medicine and DentistryJames Cook University Townsville Queensland Australia
- Townsville Clinical SchoolThe Townsville Hospital Townsville Queensland Australia
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