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

doi:10.1016/j.jpedsurg.2005.12.054

Journal of Pediatric Surgery

Volume 41, Issue 5, May 2006, Pages 1020-1024

https://doi.org/10.1016/j.jpedsurg.2005.12.054 Get rights and content

Abstract

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.

Section snippets

Methods

A retrospective review of the most recent 250 patients with perforated appendicitis treated at our institution was conducted. This series spanned the past 6 years. The group of patients treated with once-a-day dosing of ceftriaxone and metronidazole (group 1) was compared with the most recent cohort treated with triple antibiotic coverage (group 2). There was a rapid shift in treatment plan from group 2 to group 1 approximately 2 years before data collection; however, there was some overlap

Patients

The 2-drug regimen of ceftriaxone and metronidazole (group 1) was used in 57 patients compared with 193 patients treated with triple antibiotic coverage (group 2). Patient demographics included a mean age of 9.1 ± 0.5 years with a range of 2 to 15 years compared with a mean of age of 7.7 ± 0.3 years with a range 2 to 18 years in group 2. Sex consisted of 64.9% males in group 1 and 67.9% males in group 2.

Presentation

Leukocyte count on admission was 17.8 ± 0.8 × 10³ white blood cells in group 1 compared with

Discussion

The impetus for defining a simplified postoperative antibiotic regimen is a strong one. Monotherapy with newer broad-spectrum agents such as piperacillin/tazobactum for intraabdominal infections has recently been demonstrated to be equally efficacious as traditional triple therapy [14], [15]. Similarly, cefotaxime, a cephalosporin with a similar profile to ceftriaxone, has been shown to be equal to the aforementioned monotherapy schedule of piperacillin/tazobactum in children with complicated

Conclusions

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Cited by (41)

Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study
2024, Surgery (United States)
To decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections.
The aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention.
A total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups.
Our quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.
Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam Versus Ceftriaxone with Metronidazole
2023, Journal of Pediatric Surgery
Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database.
We queried the Pediatric Health Information System for patients 2–18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated.
We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04–1.75) and readmission (RR 1.38, 99% CI 1.13–1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant.
Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns.
Level III.
Retrospective Comparative Study.
Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative
2023, Journal of Pediatric Surgery
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.
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.
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).
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.
Quality improvement.
Level III.
Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis
2021, Journal of Surgical Research
Although perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis.
This is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared.
Forty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively.
Provider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.
The future of publishing
2019, Journal of Pediatric Surgery
Pediatric Appendicitis
2017, Surgical Clinics of North America
Citation Excerpt :
Both piperacillin/tazobactam and cefoxitin have been shown to be at least as efficacious as the triple-drug regimen and may also decrease length of stay (LOS) and pharmaceutical costs.60 Other studies suggest that metronidazole must be added to a third-generation cephalosporin to cover anaerobic isolates.61,62 The authors’ center begins with a single dose of ceftriaxone sodium (Rocephin) and metronidazole (Flagyl).

View all citing articles on Scopus

: Presented at the 37th Annual Meeting of the Canadian Association of Paediatric Surgeons, Quebec, Canada, September 22-25, 2005.

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CAPS Original paperA simple and more cost-effective antibiotic regimen for perforated appendicitis

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Methods

Patients

Presentation

Discussion

Conclusions

Am J Surg

Diagn Microbiol Infect Dis

Int J Antimicrob Agents

A multicenter randomized trial of prophylaxis with intravenous cefepime + metronidazole or ceftriaxone + metronidazole in colorectal surgery. The 230 Study Group

J Chemother

Short-term prophylaxis with ceftriaxone plus metronidazole in esophageal cancer surgery

J Chemother

Perioperative infection prophylaxis and risk factor impact in colon surgery

Chemotherapy

Ceftriaxone vs. ampicillin + metronidazole as prophylaxis against infections after clean-contaminated abdominal surgery

Eur J Surg

Ceftriaxone (Rocephin) in abdominal trauma

J Trauma

A cost-effectiveness evaluation of 3 antimicrobial regimens for the prevention of infective complications after abdominal surgery

Arch Surg

A prospective, randomised comparison of single- vs. multiple-dose antibiotic prophylaxis in penetrating trauma

Chemotherapy

Strategies for cost-containment: once-daily ceftriaxone plus amikacin as empiric therapy for febrile granulocytopenic children with cancer

J Chemother

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