Determining duration of antibiotic use in children with complicated appendicitis
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D J Hoelzer1, D D Zabel, J T Zern
1Department of Surgery, Christiana Care Health System, Wilmington, DE 19718, USA.
Insights
Discontinuing antibiotics for children with complicated appendicitis is safe when they are afebrile, eating, and have normal white blood cell (WBC) counts with few immature neutrophils. This approach minimizes the risk of recurrent intraabdominal abscesses.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
- Critical Care Medicine
Background:
- Broad-spectrum antibiotics have significantly reduced mortality and morbidity in children with complicated appendicitis.
- Current recommendations involve 3-14 days of postoperative antibiotics, with duration determined by the physician.
- Complicated appendicitis includes gangrenous or perforated cases.
Purpose of the Study:
- To evaluate if specific clinical criteria can safely guide the discontinuation of antibiotics in children with complicated appendicitis.
- To determine if a combination of being afebrile, eating, and having a normal white blood cell (WBC) count with ≤3% band forms is a reliable endpoint for antibiotic therapy.
Main Methods:
- A prospective study of 33 consecutive pediatric patients with perforated or gangrenous appendicitis.
- All patients received standardized resuscitation, appendectomy, and broad-spectrum antimicrobial therapy.
- Antibiotics were continued until patients were afebrile, eating, and had normal WBC counts with ≤3% immature neutrophils (band forms).
Main Results:
- Of 32 patients treated to criteria, 31 (97%) recovered without complications like intraabdominal abscess or wound infection.
- One patient who met criteria required rehospitalization for an intraabdominal abscess.
- Another patient, discharged prematurely despite not being afebrile, was readmitted for abscess drainage, indicating 100% predictive value for criterion mismatch.
Conclusions:
- Antibiotic therapy can be safely discontinued in pediatric patients with complicated appendicitis when they are afebrile for 24 hours, eating, and have a WBC count with ≤3% band forms.
- This approach presents a low risk of recurrent intraabdominal abscess.
- The study supports using these clinical parameters to guide antibiotic cessation.
Background:
The introduction of broad spectrum antibiotics has substantially decreased rates of mortality and morbidity associated with complicated appendicitis in children. The generally recommended therapy for children with complicated (gangrenous or perforated) appendicitis is administration of postoperative antibiotics for 3 to 14 days, but the decision as to the specific duration of treatment lies with the treating physician.
Aim:
This study evaluates whether the recommendation that the combination of the patient's being afebrile and eating and having a normal white blood cell (WBC) count and < or = 3% band forms can be used to decide when sufficient antibiotics have been given and can be safely discontinued.
Methods:
Thirty-three consecutive patients seen in the pediatric surgical service with perforated or gangrenous appendicitis were studied prospectively. All patients received a standard protocol of resuscitation, appendectomy and broad spectrum antimicrobial therapy to be continued until they were eating, afebrile and had normal white blood cell counts with < or = 3% immature neutrophils (band forms).
Results:
Thirty-two children were treated until they met all criteria when antibiotics were stopped and the patients were discharged. Of these patients 31 had unremarkable courses of recovery with no development of intraabdominal abscess or wound infection [predictive value of criteria, 97% (31 of 32)]. The remaining patient who met the criteria required rehospitalization for treatment of intraabdominal abscess. Another patient was discharged prematurely when he failed to meet the criterion of afebrility. Although he was eating and his WBC count was normal, he had a temperature of 38.5 degrees C during the 24 h before discharge. He was readmitted for surgical drainage of an intraabdominal abscess, yielding a 100% predictive value for the criterion mismatch (1 of 1).
Conclusion:
Based on our observations, when a patient with complicated appendicitis is afebrile for 24 h (temperature < 38 degrees C), is eating and has a WBC count with < or = 3% band forms, antibiotics can be safely discontinued with small risk of recurrent intraabdominal abscess.
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