Duration of post-operative antibiotic treatment in acute complicated appendicitis: systematic review and meta-analysis

Antibiotic treatment after appendectomy for acute complicated appendicitis to prevent intrabdominal abscess and wound infections

INTRODUCTION

The purpose of this analysis was to investigate the most appropriate duration of postoperative antibiotic treatment to minimize the incidence of intraabdominal abscesses and wound infections in patients with complicated appendicitis.

MATERIALS AND METHODS

In this retrospective study, which included 396 adult patients who underwent appendectomy for complicated appendicitis between January 2010 and December 2020 at the University Hospital Erlangen, patients were classified into two groups based on the duration of their postoperative antibiotic intake: ≤ 3 postoperative days (group 1) vs. ≥ 4 postoperative days (group 2). The incidence of postoperative intraabdominal abscesses and wound infections were compared between the groups. Additionally, multivariate risk factor analysis for the occurrence of intraabdominal abscesses and wound infections was performed.

RESULTS

The two groups contained 226 and 170 patients, respectively. The incidence of postoperative intraabdominal abscesses (2% vs. 3%, p = 0.507) and wound infections (3% vs. 6%, p = 0.080) did not differ significantly between the groups. Multivariate analysis revealed that an additional cecum resection (OR 5.5 (95% CI 1.4-21.5), p = 0.014) was an independent risk factor for intraabdominal abscesses. A higher BMI (OR 5.9 (95% CI 1.2-29.2), p = 0.030) and conversion to an open procedure (OR 5.2 (95% CI 1.4-20.0), p = 0.016) were identified as independent risk factors for wound infections.

CONCLUSION

The duration of postoperative antibiotic therapy does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections. Therefore, short-term postoperative antibiotic treatment should be preferred.

Current use of artificial intelligence in the diagnosis and management of acute appendicitis

INTRODUCTION

Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives.

EVIDENCE ACQUISITION

We performed a literature search on articles published from 2018 to September 2023. We included only original articles.

EVIDENCE SYNTHESIS

Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis.

CONCLUSIONS

AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.

SAGES guideline for the diagnosis and treatment of appendicitis

BACKGROUND

Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis.

METHODS

A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts.

RESULTS

Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty.

CONCLUSIONS

These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial

OBJECTIVE

To compare costs for 2 days versus 5 days of postoperative antibiotics within the antibiotics after an aPPendectomy In Complex appendicitis trial.Background:Recent studies suggest that restrictive antibiotic use leads to a significant reduction in hospital stays without compromising patient safety. Its potential effect on societal costs remains underexplored.

METHODS

This was a pragmatic, open-label, multicenter clinical trial powered for noninferiority. Patients with complex appendicitis (age ≥ 8 years) were randomly allocated to 2 days or 5 days of intravenous antibiotics after appendectomy. Patient inclusion lasted from June 2017 to June 2021 in 15 Dutch hospitals. The final follow-up was on September 1, 2021. The primary trial endpoint was a composite endpoint of infectious complications and mortality within 90 days. In the present study, the main outcome measures were overall societal costs (comprising direct health care costs and costs related to productivity loss) and cost-effectiveness. Direct health care costs were recorded based on data in the electronic patient files, complemented by a telephone follow-up at 90 days. In addition, data on loss of productivity were acquired through the validated Productivity Cost Questionnaire at 4 weeks after surgery. Cost estimates were based on prices for the year 2019.

RESULTS

In total, 1005 patients were evaluated in the "intention-to-treat" analysis: 502 patients were allocated to the 2-day group and 503 to the 5-day group. The mean difference in overall societal costs was - €625 (95% CI: -€ 958 to -€ 278) to the advantage of the 2-day group. This difference was largely explained by reduced hospital stay. Productivity losses were similar between the study groups. Restricting postoperative antibiotics to 2 days was cost-effective, with estimated cost savings of €31,117 per additional infectious complication.

CONCLUSIONS

Two days of postoperative antibiotics for complex appendicitis results in a statistically significant and relevant cost reduction, as compared with 5 days. Findings apply to laparoscopic appendectomy in a well-resourced health care setting.

Short Postoperative Intravenous Versus Oral Antibacterial Therapy in Complicated Acute Appendicitis: A Pilot Noninferiority Randomized Trial

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.

Cessation of Antibiotics for Complicated Appendicitis at Discharge Does Not Increase Risk of Post-operative Infection

PURPOSE

The utilization of home antibiotic therapy following surgery for complicated pediatric appendicitis is highly variable. In 2019, we stopped home antibiotic therapy in this cohort at our institution. We sought to evaluate our outcomes following this protocol change.

METHODS

We queried our institutional NSQIP Pediatrics data for all children undergoing appendectomy for complicated appendicitis between January 2015 and May 2022. We identified two cohorts: those discharged with home antibiotics (1/1/15-4/30/19) and those discharged with no home antibiotics (5/1/19-4/30/22). Both groups were treated with response based parenteral antibiotics while hospitalized and discharged when clinically well. Our primary outcome was postoperative deep organ space infection requiring intervention (drainage, aspiration, reoperation, or antibiotics). Secondary outcomes included length of stay, superficial site infection, Clostridium difficile colitis, ER visits, post-operative CT imaging, and readmission.

RESULTS

There were 185 patients in the home antibiotic group (83% discharged with antibiotics) and 121 patients in the no home antibiotic group (8.3% discharged with antibiotics). There were no significant differences in deep organ space infection requiring intervention (7% vs. 7.4%, p = 1.0). Our length of stay was not different (4.5 days vs. 3.95 days, p = 0.32), nor were other secondary outcomes or patient characteristics. All patients had documented follow-up.

CONCLUSIONS

We did not identify differences in deep organ space infections, length of stay or other events after eliminating home antibiotic therapy in our complicated appendicitis cohort. The use of home antibiotics following surgery for complicated appendicitis should be reconsidered.

LEVEL OF EVIDENCE

III.

Antibiotic therapy and necrotizing enterocolitis

Antibiotic therapy remains a cornerstone of treatment of both medical and surgical presentations of necrotizing enterocolitis (NEC). However, guidelines regarding the administration of antibiotics for the treatment of NEC are lacking and practices vary amongst clinicians. Although the pathogenesis of NEC is unknown, there is consensus that the infant gastrointestinal microbiome contributes to the disease. The presumed connection between dysbiosis and NEC has prompted some to study whether early prophylactic enteral antibiotics can prevent NEC. Yet others have taken an opposing approach, studying whether perinatal antibiotic exposure increases the risk of NEC by inducing a state of dysbiosis. This narrative review summarizes what is known about antibiotics and their association with the infant microbiome and NEC, current antibiotic prescribing practices for infants with medical and surgical NEC, as well as potential strategies to further optimize the use of antibiotics in this population of infants.

The Prognostic Significance of Red Cell Distribution Width in Cardiac Surgery: A Systematic Review and Meta-Analysis

RED CELL DISTRIBUTION WIDTH (RDW) is a routinely available biomarker of likely erythropoietic dysfunction, which may be associated with adverse outcomes after cardiac surgery. This systematic review and meta-analysis aimed to clarify the prognostic value of RDW in patients undergoing cardiac surgery. The authors searched MEDLINE, Embase, and the Cochrane Library from inception to May 10, 2022 for studies investigating the association between elevated RDW (as defined by the authors of included studies) and adverse outcomes after cardiac surgery. Herein, the authors extracted maximally adjusted hazard ratios (HRs) and odds ratios (ORs) with associated CIs, and pooled them using random-effects inverse- variance modeling. The authors explored interstudy heterogeneity using metaregression. The authors included 26 studies involving 48,092 patients who had undergone cardiac surgery. Elevated preoperative RDW was associated with long-term mortality (pooled HR 1.63, 95% CI 1.05-2.52), short-term mortality (pooled OR 2.16, 95% CI 1.21-3.87), acute kidney injury (AKI; pooled OR 1.30, 95% CI 1.19-1.41) and postoperative atrial fibrillation (POAF; pooled OR 1.44, 95% CI 1.05-1.96). Some studies suggested a significant association between preoperative RDW elevation and neurologic complications; however, their number was insufficient for meta-analysis. The postoperative RDW levels were less consistently reported and could not be meta-analyzed. In conclusion, the authors found that elevated preoperative RDW was associated with increased short- and long-term mortality, POAF, and AKI after cardiac surgery. Further research is needed to investigate its role in the risk stratification of patients undergoing cardiac surgery.

2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial

BACKGROUND

The appropriate duration of postoperative antibiotics for complex appendicitis is unclear. The increasing global threat of antimicrobial resistance warrants restrictive antibiotic use, which could also reduce side-effects, length of hospital stay, and costs.

METHODS

In this pragmatic, open-label, non-inferiority trial in 15 hospitals in the Netherlands, patients with complex appendicitis (aged ≥8 years) were randomly assigned (1:1) to receive 2 days or 5 days of intravenous antibiotics after appendicectomy. Randomisation was stratified by centre, and treating physicians and patients were not masked to treatment allocation. The primary endpoint was a composite endpoint of infectious complications and mortality within 90 days. The main outcome was the absolute risk difference (95% CI) in the primary endpoint, adjusted for age and severity of appendicitis, with a non-inferiority margin of 7·5%. Outcome assessment was based on electronic patient records and a telephone consultation 90 days after appendicectomy. Efficacy was analysed in the intention-to-treat and per-protocol populations. Safety outcomes were analysed in the intention-to-treat population. This trial was registered with the Netherlands Trial Register, NL5946.

FINDINGS

Between April 12, 2017, and June 3, 2021, 13 267 patients were screened and 1066 were randomly assigned, 533 to each group. 31 were excluded from intention-to-treat analysis of the 2-day group and 30 from the 5-day group owing to errors in recruitment or consent. Appendicectomy was done laparoscopically in 955 (95%) of 1005 patients. The telephone follow-up was completed in 664 (66%) of 1005 patients. The primary endpoint occurred in 51 (10%) of 502 patients analysed in the 2-day group and 41 (8%) of 503 patients analysed in the 5-day group (adjusted absolute risk difference 2·0%, 95% CI -1·6 to 5·6). Rates of complications and re-interventions were similar between trial groups. Fewer patients had adverse effects of antibiotics in the 2-day group (45 [9%] of 502 patients) than in the 5-day group (112 [22%] of 503 patients; odds ratio [OR] 0·344, 95% CI 0·237 to 0·498). Re-admission to hospital was more frequent in the 2-day group (58 [12%] of 502 patients) than in the 5-day group (29 [6%] of 503 patients; OR 2·135, 1·342 to 3·396). There were no treatment-related deaths.

INTERPRETATION

2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days in terms of infectious complications and mortality within 90 days, based on a non-inferiority margin of 7·5%. These findings apply to laparoscopic appendicectomy conducted in a well resourced health-care setting. Adopting this strategy will reduce adverse effects of antibiotics and length of hospital stay.

FUNDING

The Netherlands Organization for Health Research and Development.

The prognostic value of elevated neutrophil-lymphocyte ratio for cardiac surgery-associated acute kidney injury: A systematic review and meta-analysis

BACKGROUND

Patients undergoing cardiac surgery are at significant risk of developing postoperative acute kidney injury (AKI). Neutrophil-lymphocyte ratio (NLR) is a widely available inflammatory biomarker which may be of prognostic value in this setting.

METHODS

We conducted a systematic review and meta-analysis of studies reporting associations between perioperative NLR with postoperative AKI. We searched Medline, Embase and the Cochrane Library, without language restriction, from inception to May 2022 for relevant studies. We meta-analysed the reported odds ratios (ORs) with 95% confidence intervals (CIs) for both elevated preoperative and postoperative NLR with risk of postoperative AKI and need for renal replacement therapy (RRT). We conducted a meta-regression to explore inter-study statistical heterogeneity.

RESULTS

Twelve studies involving 10,724 participants undergoing cardiac surgery were included, with eight studies being deemed at high risk of bias using PROBAST modelling. We found statistically significant associations between elevated preoperative NLR and postoperative AKI (OR 1.45, 95% CI 1.18-1.77), as well as postoperative need for RRT (OR 2.37, 95% CI 1.50-3.72). Postoperative NLR measurements were not of prognostic significance.

CONCLUSIONS

Elevated preoperative NLR is a reliable inflammatory biomarker for predicting AKI following cardiac surgery.

The association between platelet indices and presence and severity of psoriasis: a systematic review and meta-analysis

The role of platelet function indices-platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), plateletcrit (PCT), immature platelet fraction (IPF), and platelet mass index (PMI)-in psoriasis is uncertain. This systematic review and meta-analysis aimed to evaluate the association of these platelet biomarkers with both presence and severity of psoriasis. We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception to November 2021. To evaluate the association of platelet function indices and psoriasis, we recorded mean differences (MD) and 95% confidence intervals (CI) as well as correlation coefficients (r) for each included study, and generated summary estimates using random-effects inverse-variance modelling. We screened 1,079 unique studies, and included 33 studies with 6724 patients in the quantitative analyses. Compared with controls, patients with psoriasis had higher PLT (MD 12.86 × 10⁹/L, 95% CI 6.34-19.39, p < 0.001), MPV (MD 0.61fL, 95% CI 0.31-0.92, p < 0.001), and PCT (MD 0.05%, 95% CI 0.01-0.09, p = 0.010), but similar PDW (MD 0.16%, 95% CI -0.46-0.79, p = 0.610). Psoriasis Area and Severity Index (PASI) was weakly correlated with PLT (r 0.17, 95% CI 0.06-0.28, p = 0.003), MPV (r 0.36, 95% CI 0.22-0.49, p < 0.001), and PDW (r 0.17, 95% CI 0.08-0.26, p < 0.001). Study numbers were insufficient to judge the relationship of IPF and PMI with psoriasis presence, or PCT, IPF, and PMI with psoriasis severity. In summary, PLT, MPV, and PCT are significantly elevated in patients with psoriasis, and PLT, MPV, and PDW are weakly correlated with PASI. Future studies are needed to evaluate the independent diagnostic and prognostic potentials of these biomarkers in patients with psoriasis.

Donor Cardiac Troponin for Prognosis of Adverse Outcomes in Cardiac Transplantation Recipients: a Systematic Review and Meta-analysis

BACKGROUND

Cardiac troponin is a highly specific and widely available marker of myocardial injury, and elevations in cardiac transplant donors may influence donor selection. We aimed to investigate whether elevated donor troponin has a role as a prognostic biomarker in cardiac transplantation.

METHODS

In a systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library, without language restriction, from inception to December 2020. We included studies reporting the association of elevated donor troponin with recipient outcome after cardiac transplant. We generated summary odds ratios and hazard ratios for the association of elevated donor troponin with short- and long-term adverse outcomes. Methodological quality was monitored using the Quality In Prognosis Studies tool, and interstudy heterogeneity was assessed using a series of sensitivity and subgroup analyses.

RESULTS

We included 17 studies involving 15 443 patients undergoing cardiac transplantation. Elevated donor troponin was associated with increased odds of graft rejection at 1 y (odds ratio, 2.54; 95% confidence interval, 1.22-5.28). No significant prognostic relationship was found between donor troponin and primary graft failure, short- to long-term mortality, cardiac allograft vasculopathy, and pediatric graft loss.

CONCLUSIONS

Elevated donor troponin is not associated with an increased short- or long-term mortality postcardiac transplant despite increasing the risk of graft rejection at 1 y. Accordingly, an elevated donor troponin in isolation should not exclude donation.

Acute appendicitis–advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.