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Perforated appendicitis: prospective outcome analysis for 150 children
S J Fishman1, L Pelosi, S L Klavon
1Department of Surgery, Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.
Insights
This study shows that a new protocol for perforated appendicitis using a single antibiotic, piperacillin-tazobactam, and allowing outpatient treatment maintains low complication rates. This approach effectively manages appendicitis while reducing costs and length of hospital stay.
Area of Science:
- Surgical outcomes research
- Infectious disease management
- Healthcare economics
Background:
- Management of perforated appendicitis involves ongoing debate regarding antibiotic selection, duration, operative timing, drain use, and wound closure.
- Previous protocols at the institution utilized a multi-drug regimen for 10 inpatient days with drains, achieving low complication rates.
- Current healthcare pressures emphasize reduced length of stay and cost, potentially compromising clinical outcomes.
Purpose of the Study:
- To evaluate if modified management protocols for perforated appendicitis could maintain excellent clinical outcomes while decreasing costs and length of stay.
- To assess the efficacy and safety of a new protocol involving a single broad-spectrum antibiotic and early outpatient transition.
Main Methods:
- Prospective monitoring of clinical outcomes in 150 patients with perforated appendicitis over 43 months.
- Treatment involved intravenous piperacillin-tazobactam for 10 days, with potential for the final 5 days of therapy to be administered via a percutaneous intravenous catheter at home.
- Key elements of the prior protocol, including immediate surgery, Penrose drains, and primary wound closure, were maintained.
Main Results:
- Major complications were low: intra-abdominal abscess (3.3%), cecal fistula (1.3%), phlegmon (2.0%), and wound infection (2.7%).
- No small bowel obstructions requiring surgery occurred.
- The complication rates were not significantly different from a historical cohort of 373 patients treated under the previous, more intensive protocol.
Conclusions:
- A modified protocol using a single broad-spectrum antibiotic, piperacillin-tazobactam, can effectively treat perforated appendicitis with minimal infectious complications.
- This approach allows for cost savings through outpatient administration of the final antibiotic course without compromising quality of care.
- The study provides essential outcome data for comparison with future treatment modifications aimed at reducing healthcare costs.
Background/Purpose:
Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration, operative timing, drain utilization, and wound closure. For 2 decades at the authors' institution, patients were treated with ampicillin, gentamicin, and clindamycin for 10 inpatient days, with drains in the abdomen, resulting in lower complication rates than most other published series. Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes. In addition, there are little prospective data on clinical outcomes. The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aimed at decreasing cost and length of stay in our protocol were instituted.
Methods:
The authors monitored prospectively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period. Patients received a single antibiotic, piperacillin-tazobactam, intravenously for 10 days. They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met. Other practices from our earlier protocol were continued, including immediate operation, placement of Penrose drains, and primary wound closure.
Results:
Of 150 patients treated on our protocol, major complications included intraabdominal abscess in 5 (3.3%), cecal fistula in 2 (1.3%), phlegmon in 3 (2.0%), wound infection in 4 (2.7%), and no small bowel obstructions requiring operation. None of these complications, nor their aggregate, were significantly more common than those reported in 373 patients treated over 11 years on the authors' prior protocol (chi2, P > .05).
Conclusions:
Prospective outcome analysis of our protocol shows that a single broad-spectrum antibiotic (allowing portions of therapy to be delivered less expensively on an outpatient basis) effectively can treat postoperative appendicitis with very few infectious complications. These outcome data provide baseline against which future protocols can be compared. All treatment modifications aimed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised.