Background: Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. Antibiotic choice for appendicitis varies widely across childrens hospitals, and the optimal antibiotic regimen for perforated appendicitis remains unclear.
Methods: Retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large, tertiary care childrens hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes and confirmed by chart review. Patients were excluded if they had been admitted for ≥48 hours prior to diagnosis, had a prior history of appendicitis, received inotropic agents, were immunocompromised, or received an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an antipseudomonal regimen (including cefepime, piperacillin-tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days of diagnosis. The primary outcome of interest was inpatient treatment failure, defined as development of wound infection or abscess prior to discharge.
Results: Of 353 children who met study inclusion criteria, 252 (71%) received CTX/MTZ and 101 (29%) received an antipseudomonal regimen. The proportion of children treated with antipseudomonal antibiotics varied across providers from 0 to 100% (See Figure). Treatment failure occurred in 13.1% of children receiving CTX/MTZ, and 15.8% of children receiving antipseudomonal antibiotics (p=0.50). Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on antipseudomonal antibiotics (p=0.32). In a multivariable logistic regression model adjusting for sex, age, race, initial white blood cell count, and underlying medical conditions, the odds of treatment failure with antipseudomonal antibiotics was 1.38 (95% CI 0.65, 2.93) compared to treatment with CTX/MTZ. Mean length of stay did not differ by treatment group.
Conclusion: Antibiotic choice for perforated appendicitis varied widely among providers. Treatment failure rates did not differ between children treated with antipseudomonal antibiotics versus CTX/MTZ.
Figure: Proportion treated with anti-pseudomonal antibiotic, by attending surgeon
R. F. Hamdy,
E. Spyridakis, None
D. Dona, None
M. Bryan, None
A. Kyriakousi, None
J. S. Gerber, None
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