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de Wijkerslooth EM, Boerma EJG, van Rossem CC, Koopmanschap MA, Baeten CI, Beverdam FH, Bosmans JW, Consten EC, Dekker JWT, Emous M, van Geloven AA, Gijsen AF, Heijnen LA, Jairam AP, van der Ploeg AP, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BP, van den Boom AL. Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial. Ann Surg 2024; 279:885-890. [PMID: 37698025 PMCID: PMC10997181 DOI: 10.1097/sla.0000000000006089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
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.
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Affiliation(s)
| | - Evert-Jan G. Boerma
- Departments of Surgery, Zuyderland Medical Center, Heerlen/Sittard, The Netherlands
| | | | - Marc A. Koopmanschap
- Departments of Surgery, Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Coen I.M. Baeten
- Departments of Surgery, Groene Hart Hospital, Gouda, The Netherlands
| | | | | | - Esther C.J. Consten
- Departments of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Departments of Surgery, University Medical Center Groningen, The Netherlands
| | | | - Marloes Emous
- Departments of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Anton F. Gijsen
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Luc A. Heijnen
- Departments of Surgery, Northwest Clinics, Alkmaar/Den Helder, The Netherlands
| | - An P. Jairam
- Departments of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Pascal Steenvoorde
- Departments of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | | | - Maarten Vermaas
- Departments of Surgery, IJsselland Hospital, Capelle a/d Ijssel, The Netherlands
| | - Bas Wiering
- Departments of Surgery, Slingeland Hospital, Doetinchem, The Netherlands
| | - Bas P.L. Wijnhoven
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
| | - Anne Loes van den Boom
- Departments of Surgery, Erasmus MC—University Medical Center, Rotterdam, The Netherlands
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van den Boom AL, de Wijkerslooth EM, Giesen LJ, van Rossem CC, Toorenvliet BR, Wijnhoven BP. Postoperative Antibiotics and Time to Reach Discharge Criteria after Appendectomy for Complex Appendicitis. Dig Surg 2023; 39:162-168. [PMID: 36041400 PMCID: PMC9909712 DOI: 10.1159/000526790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/16/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Postoperative antibiotic treatment is indicated for 3-5 days following appendectomy for complex appendicitis. However, meeting discharge criteria may allow for safe discontinuation of antibiotics and discharge. This study assessed the association between time to reach discharge criteria and duration of postoperative antibiotic use and length of stay. METHODS This is a multicenter retrospective cohort study including patients who underwent appendectomy for complex appendicitis and received postoperative antibiotics for >24 h. Main outcome measures were time to reach discharge criteria, duration of postoperative antibiotic use, length of hospital stay, and postoperative infectious complications. Discharge criteria were defined as absence of fever (temperature ≤38°C) for 24 h, ability to tolerate oral intake, and pain controlled by oral analgesics. RESULTS Between May 2014 and January 2015, 124 patients were included. Time to reach discharge criteria was 2 days (interquartile range [IQR] 1-3). Patients received postoperative antibiotics and were in hospital for a median of 5 (IQR 3-5) and 5 (IQR 4-6) days, respectively. Infectious complications occurred in 12% and did not differ between patients reaching discharge criteria before or after 2 postoperative days. DISCUSSION Discharge criteria were met by a median of 2 days after appendectomy for complex appendicitis. This suggests that postoperative antibiotics duration and thereby hospital stay can be reduced. In daily practice, prescribed antibiotics are not reduced in total days given. Prospective studies that evaluate limited postoperative antibiotic use, based on these criteria, are necessary.
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Affiliation(s)
- Anne Loes van den Boom
- Department of Surgery, Erasmus MC − University Medical Centre, Rotterdam, The Netherlands,*Anne Loes van den Boom, a.vandenboomüerasmusmc.nl
| | | | - Louis J.X. Giesen
- Department of Surgery, Erasmus MC − University Medical Centre, Rotterdam, The Netherlands
| | | | | | - Bas P.L. Wijnhoven
- Department of Surgery, Erasmus MC − University Medical Centre, Rotterdam, The Netherlands
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