Accuracy of computed tomography in predicting appendiceal perforation

Background

Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans.

Methods

A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups.

Results

In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%.

Conclusions

This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.     

Appendiceal fecalith is associated with early perforation in pediatric patients

Purpose

A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation.

Methods

Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings.

Results

There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036).

Conclusion

The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith.     

Comparison of pediatric appendicitis outcomes between teaching and nonteaching hospitals

Purpose

The aim of the study was to determine the outcomes of pediatric appendicitis between a teaching and nonteaching institution.

Methods

A retrospective review of all patients younger than 18 years treated for appendicitis between 1998 and 2007 was performed. The teaching institution has its own general surgery residency program, and the nonteaching institution has no surgical resident involvement. Both hospitals are part of a larger system and were similar except for resident involvement. Study outcomes included postoperative morbidity and length of hospitalization (LOH). Patients with perforated appendicitis treated nonoperatively were excluded. Data were analyzed using Wilcoxon rank sum test and χ² analysis with P < .01 considered significant.

Results

Seven hundred ninety-two patients were treated at the teaching institution (mean age, 10.9 years; 62% male) and 1670 at the nonteaching institution (mean age, 11 years; 61% male). The perforated appendicitis rate was 31% at the teaching institution and 26% at the nonteaching institution (P = .008). Forty-five patients at the teaching institution and 14 at the nonteaching institution with perforated appendicitis were treated nonoperatively and excluded. For nonperforated appendicitis, despite similar rates of postoperative wound infection, abscess drainage, and readmission within 30 days between the 2 institutions, LOH was shorter in the teaching institution (1.4 ± 1.0 vs 1.8 ± 1.4 days; P < .0001). For perforated appendicitis, LOH and rates of wound infection, abscess drainage, and readmission within 30 days were similar between the 2 institutions.

Conclusions

Children with nonperforated appendicitis cared for at a teaching institution had similar postoperative morbidity and shorter LOH compared to a nonteaching institution. In patients with perforated appendicitis, postoperative morbidity and LOH were similar between teaching and nonteaching institutions. Overall, the presence of surgical trainees did not adversely impact on the quality of care for children with appendicitis.     

Association between the appendix and the fecalith in adults

Background

We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix.

Methods

We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith.

Results

During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10–76) years. The fecalith rate was 13%–16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma.

Conclusion

Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.     

A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial

Introduction

In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics.

Methods

Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days.

Results

One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm.

Conclusions

When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.     

Pediatric appendicitis in New England: epidemiology and outcomes

Background

Acute appendicitis is among the most common indications for surgery in children in the Western world. The epidemiology of acute appendicitis in the United States has not been recently analyzed in a population-based cohort study.

Methods

Here, we describe the epidemiology of acute appendicitis in the pediatric population in New England from 2000 to 2006.

Results

Our results show that there is clustering of perforated and nonperforated appendicitis by hospital catchment area (Moran I index 0.01 and 0.03, respectively). The overall incidence of nonperforated appendicitis decreased over our study period by 9.7% (P < .05), the proportion of perforated appendicitis did not change significantly over our study period, and there was a 38% decrease in the proportion of negative appendectomies (P < .05).

Conclusions

There were trends toward increased operative volume for pediatric surgeons as well as sharp increases in the use of laparoscopy and early discharge with home health services. Our results demonstrate that the epidemiology, outcomes, and trends in treatment of acute appendicitis continue to change.     

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

Objective

The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.

Data Source

Data were obtained from PubMed, MEDLINE, and citation review.

Study Selection

We conducted a literature search using “appendicitis” combined with “antibiotics” with children as the target patient population. Studies were selected based on relevance for the following questions:

(1)

What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis?

(2)

For patients with perforated appendicitis treated with appendectomy:

a.

What perioperative intravenous antibiotics should be used?

b.

How long should perioperative intravenous antibiotics be used?

c.

Should oral antibiotics be used?

(3)

For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?

Results

Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.

Conclusions

Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.     

Routine interval appendectomy in children is not indicated

Background

This study evaluates outcomes for children treated without interval appendectomy (IA) after successful nonoperative management of perforated appendicitis.

Methods

A retrospective study of pediatric patients with appendicitis was performed from 12 regional acute-care hospitals from 1992 to 2004 with mean length of follow-up of 7.5 years. Main outcomes were recurrent appendicitis and cumulative length of hospital stay.

Results

The study included 6439 patients, of which 6367 (99%) underwent initial appendectomy. Seventy-two (1%) patients were initially managed nonoperatively and 11 patients had IA. Of the remaining 61 patients without IA, 5 (8%) developed recurrent appendicitis. Age, sex, type of appendicitis, and abscess drainage had no influence on recurrent appendicitis. Cumulative length of hospital stay was 6.6 days in patients without IA, 8.5 days in patients with IA, and 9.6 days in patients with recurrent appendicitis.

Conclusion

Recurrent appendicitis is rare in pediatric patients after successful nonoperative management of perforated appendicitis. Routine IA is not necessarily indicated for these children.     

Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis with abscess

Objective

Given the perceived technical demands of laparoscopic appendectomy and the expected postoperative morbidity in patients with a well-defined abscess, initial percutaneous drainage has become an attractive option in this patient population. This strategy allows for a laparoscopic appendectomy to be performed in an elective manner at the convenience of the surgeon. However, the medical burden on the patient and on the quality of patient outcomes has not been described in the literature. Therefore, we audited our experience with initial percutaneous drainage followed by laparoscopic interval appendectomy to evaluate the need for a prospective trial.

Methods

After institutional review board approval, a retrospective chart review was performed on all children who presented with perforated appendicitis and a well-defined abscess and were treated by initial percutaneous aspiration/drainage followed by interval appendectomy between January 2000 and September 2006. Continuous variables are listed with standard deviation.

Results

There were 52 patients with a mean age of 9.0 ± 3.9 years and weight of 34.4 ± 18.8 kg. The mean duration of symptoms at presentation was 8.4 ± 7.6 days. Percutaneous aspiration only was performed in 2 patients. The mean volume of fluid on initial aspiration/drain placement was 76.3 ± 81.1 mL. The mean time to appendectomy was 61.9 ± 25.2 days. The laparoscopic approach was used in 49 patients (94.2%), of which one was converted to an open operation. The mean length of hospitalization after interval appendectomy was 1.4 ± 1.4 days. A recurrent abscess developed in 17.3% of the patients. Six patients (11.5%) required another drainage procedure. The mean total charge to the patients was $40,414.02. There were 4 significant drain complications (ileal perforation, colon perforation, bladder perforation, and buttock/thigh necrotizing abscess). The child with the ileal perforation after drain placement is the only patient who failed initial nonoperative therapy.

Conclusions

The use of initial percutaneous aspiration/drainage of periappendiceal abscess followed by interval appendectomy is an effective approach. However, this management poses complication risks and uses considerable resources. Therefore, this strategy should be compared with early operation in a prospective trial.     

Appendicitis in the obese child

Background/Purpose

Little data exist that examine the surgical challenges of obese children. We hypothesize that obesity affects the presentation, diagnosis, surgery, and postoperative course in children with appendicitis.

Methods

Cases of all children treated for appendicitis over 6 years were reviewed retrospectively. Demographics, presentation, pathology, and hospital course were examined.

Results

A total of 282 cases were reviewed; 25 were moderately obese and 31 very obese (VO), which were defined, respectively, as greater than 1.5 and greater than 2 standard deviations above the standardized mean weight for age. Groups were similar in age, sex, presentation, use of ultrasound, and surgical management. Compared with the nonobese group, median operative time was higher in the VO group (63.5 vs 55.5 minutes; P = .028), with the association between obesity and longer operative time maintained when stratifying for perforated/nonperforated and open/laparoscopic cases. Almost twice as many VO children were in the hospital for more than 5 days (nonobese 23.6%, VO 40.0% [odds ratio, 2.2; 95% confidence interval, 0.99-4.8]). This association between obesity and longer length of stay was seen when stratifying for both perforated and nonperforated cases. In the perforated group, higher rates of postoperative wound infections and significantly longer times to full diet and ambulation likely contributed to these longer stays.

Conclusions

Childhood obesity is associated with longer surgery and hospital stays and increased risk of postoperative infections. Obesity should be considered an important variable when looking at surgical outcomes in the pediatric population.     

Postoperative bowel obstruction after laparoscopic and open appendectomy in children: a 15-year experience

Purpose

The purpose of the study was to determine and evaluate the incidence of postoperative bowel obstruction (PBO) after laparoscopic and open appendectomy in children.

Material and Methods

The medical files of children who have undergone an appendectomy, either via the laparoscopic or open approach, at our department from 1992 until 2007 were reviewed. Collected data included age at appendectomy, initial surgical approach, time interval to PBO, and type of definitive treatment. The incidences of PBO after laparoscopic and open appendectomy were compared with the χ² analysis.

Results

From the 1684 children who were found, 1371 had nonperforated appendicitis and 313 had perforated appendicitis. Laparoscopic appendectomy was performed in 954 patients of the nonperforated group and in 221 of the perforated group. Open appendectomy was performed in 417 and 92 patients of the 2 groups, respectively. Overall, the incidence of PBO development was 2.2%. In the laparoscopic appendectomy population, a significantly low incidence of 1.19% of PBO development was detected, compared with the 4.51% of the open appendectomy group (P < .0001).

Conclusion

Laparoscopic appendectomy diminishes the potential of PBO development. The overall incidence of PBO is not related to the severity of the disease but only to the initial operative approach.     

Outcome of laparoscopic appendectomy for perforated appendicitis in children

Background

The aim of this study was to evaluate the outcome of laparoscopic (LA) vs open appendectomy (OA) in patients with perforated appendicitis in our center.

Methods

Retrospective review from July 2002 to April 2007 (institutional review board-approved), evaluating 281 patients with perforated appendicitis based on surgical approach. We compared demographics, mean operative time, length of stay (LOS), infectious complications, and follow-up in patients with OA (n = 213) and LA (n = 68).

Results

Laparoscopic appendectomy patients were significantly older (12 vs 9.4 years), heavier (51.8 vs 36.6 kg) and more frequently girls (47.8% vs 34.3%). Mean operative time was longer in LA (72.6 vs 50.2 minutes). Median LOS was 5 days in LA and 6 days in OA. Few patients in each group required a drainage procedure for a persistent abscess (LA 4.4%, OA 4.7%; P = 1.000). Laparoscopic appendectomy patients had fewer wound infections (1.5% vs 9.5%; P = .034), and less follow-up visits were needed (>2 clinic visits 4.5% vs 16.4%; P = .013).

Conclusion

Laparoscopic appendectomy has a shorter median LOS, a trend toward less postoperative infectious complications, and fewer clinic visits than OA, which makes it a safe and effective procedure for patients with perforated appendicitis.     

Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

Introduction

The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure.

Methods

Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval.

Results

Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001).

Conclusion

Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.     

Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

Introduction

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.

Methods

After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an α of .5 and a power of 0.82.

Results

One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.

Conclusions

Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.     

Perforated appendicitis in children: is there a best treatment?

Purpose

This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors’ hospital.

Methods

This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital.

Results

The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management.

Conclusions

Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm³. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.     

Predictive value of white blood cell count and C-reactive protein in children with appendicitis

Background/Purpose

Few studies have addressed the predictive value of white blood cells (WBCs) and C-reactive protein (CRP) at different cutoff values in appendicitis. Our purpose was to determine the cutoff values for WBC and CRP at different periods during clinical evolution of appendicitis and to establish their use for the diagnosis of appendicitis and differentiation of simple from perforated appendicitis.

Methods

We studied 198 patients operated on for appendicitis, which were further divided into 4 subgroups according to the time from the onset of symptoms to diagnosis. Receiver operating characteristic curves were constructed for CRP and WBC; the best cutoff points were used to calculate the sensitivity and specificity to discriminate patients with and without appendicitis and patients with simple and perforated appendicitis.

Results

White blood cell and CRP individually and together had a high sensitivity to differentiate patients with and without appendicitis. The specificity of WBC and CRP taken individually and together to differentiate patients with simple and perforated appendicitis was high, but the sensitivity was low.

Conclusions

White blood cell and CRP could be used to support the clinical diagnosis of appendicitis, and, depending on the time from the onset of symptoms to diagnosis, to differentiate patients with and without appendicitis and discriminate simple from perforated appendicitis.     

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis

Background

The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics.

Methods

Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using χ², Fisher exact, and Student t tests.

Results

The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain).We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 ± 5.7 vs 8.8 ± 6.7 days, P = .08).

Conclusions

When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.     

A simple and more cost-effective antibiotic regimen for perforated appendicitis

Objective

Appendicitis is the most common abdominal emergency in children. When perforation is encountered, postoperative management is grounded upon the use of intravenous antibiotics. The 3-drug regimen of ampicillin, gentamicin, and clindamycin has long been the accepted standard by pediatric surgeons. Although effective and seemingly inexpensive, this regimen produces a cumbersome dosing schedule, which has inspired the search for a simpler regimen that does not compromise efficacy or expense. To this end, we have introduced a 2-drug regimen of ceftriaxone and Flagyl (Pharmacia Corporation, Chicago, Ill) with once-a-day dosing.

Methods

A retrospective review was conducted of the most recent 250 patients treated at our institution with perforated appendicitis. Patients treated since the implementation of this 2-drug regimen were compared with the recent historical cohort treated with triple antibiotic coverage. Parameters analyzed between the 2 groups included temperature curves for the first 5 postoperative days, abscess rate, length of hospitalization, length of intravenous antibiotic treatment, and medication charges.

Results

The 2-drug regimen was used in 57 patients (group 1) compared with 193 patients treated with triple antibiotic coverage (group 2). Maximum recorded temperature between the 2 groups was similar upon admission, but the mean maximum temperature in group 1 became significantly lower than group 2 from postoperative day 1 onward (P < .001). Postoperatively, an abscess developed in 8.8% of group 1 compared with 14.2% of group 2, which was not significantly different (P = .37). Mean length of stay was 6.8 days in group 1 and 7.8 days in group 2 (P = .03). Medication charges to the patient were $81.32 per day in group 1 compared with $318.53 per day in group 2, translating to $1186.05 savings for 5 days.

Conclusions

Once-a-day dosing with ceftriaxone and Flagyl provides adequate antibiotic coverage for the postoperative management of perforated appendicitis in children. This regimen allows patients to more rapidly defervesce compared with traditional triple antibiotic coverage; moreover, this simple regimen provides substantial advantages for administration and expense.     

Post-operative antibiotic use in nonperforated appendicitis

Background

The appropriate use of preoperative antibiotics in patients undergoing appendectomy for acute appendicitis has been shown to decrease the rate of surgical site infections (SSIs). The benefits of postoperative courses of antibiotics in these patients, however, remain unclear.

Methods

The authors retrospectively reviewed all cases of nonperforated appendicitis performed at their institution over a 10-year period from 1997 to 2007. Patient outcomes were evaluated to include the postoperative development of SSIs, urinary tract infections, diarrhea, and Clostridium difficile infections.

Results

A total of 763 patients who underwent appendectomy for nonperforated appendicitis during the study period were identified. Five hundred seven of these patients had appropriate follow-up data and were the subjects of this study. Comparing patients who did and did not receive postoperative antibiotics, no significant differences in the rates of all SSIs (10% vs 9%, P = .64), superficial SSIs (9.3% vs 5.4%, P = .13), deep SSIs (.3% vs .5%, P = 1.0), organ space SSIs (2.8% vs 2.7%, P = .87), urinary tract infections (.6% vs .5%, P = 1.0), and diarrhea (2.5% vs 1.1%, P = .34) were found between groups.

Conclusions

The use of postoperative antibiotics in patients with nonperforated appendicitis does not decrease the rate of SSIs, while it may increase the cost of care.