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Modification of an evidence-based protocol for advanced appendicitis in children
Sara C Fallon1, Saif F Hassan, Emily L Larimer
1Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
Insights
Antibiotic resistance in children with advanced appendicitis is increasing. Peritoneal fluid cultures at surgery revealed 40% of patients had resistant bacteria, leading to a new recommended antibiotic therapy.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
- Microbiology
Background:
- An evidence-based clinical pathway for advanced appendicitis initially reduced infections and hospital stay.
- Four years post-implementation, infectious complications and antibiotic resistance increased.
- Prospective peritoneal fluid cultures were collected to optimize antibiotic therapy.
Purpose of the Study:
- To analyze peritoneal fluid microbiology in children with advanced appendicitis.
- To identify causative organisms and their antibiotic susceptibility.
- To guide empiric antibiotic therapy and reduce complication rates.
Main Methods:
- Prospective collection of peritoneal fluid cultures during appendectomy for advanced appendicitis.
- Microbiology analysis of isolates.
- Comparison of clinical and demographic data with a historic cohort.
- Statistical analysis using chi-squared, t-test, and Fisher exact test.
Main Results:
- No significant change in the intra-abdominal abscess rate (24-28%).
- Common isolates included Escherichia coli and Pseudomonas aeruginosa.
- 32% of isolates were Pseudomonas spp.; 12% were resistant to cefoxitin (Enterococcus spp. or E. coli).
Conclusions:
- 40% of children had organisms resistant or not susceptible to first-line antibiotics.
- Piperacillin-tazobactam is now recommended as empiric therapy.
- Peritoneal fluid analysis can guide tailored antibiotic treatment for advanced appendicitis.
Introduction:
We previously developed an evidence-based clinical pathway for children with advanced appendicitis. The pathway standardized the choice and duration of antibiotic therapy and established discharge criteria. Initially, the pathway led to a 50% decrease in the rate of superficial and deep surgical site infections and a significant decrease in hospital length of stay. Four years after implementation, we noted an increase in the infectious complication rate and the emergence of resistant bacteria to commonly used antibiotics. In this study, we prospectively collected peritoneal fluid cultures at the time of appendectomy in an effort to optimize our antibiotic therapy and decrease complication rates.
Methods:
Microbiology analysis of peritoneal fluid cultures obtained at the time of appendectomy was performed in patients with an intraoperative diagnosis of advanced appendicitis. Clinical information, including demographics, laboratory data, and postoperative outcomes were collected and compared to the historic cohort. X(2), Student's t-test, and Fisher exact test were used where appropriate.
Results:
The historic and prospective cohorts were similar with respect to clinical and demographic data. The postoperative intra-abdominal abscess rate remained unchanged (28% from 24%, P = 0.603). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated aerobic bacteria from peritoneal fluid in the prospective cohort. Thirty-two percent of these patients had Pseudomonas spp., and 12% had Enterococcus spp. or Escherichia coli resistant to cefoxitin in their peritoneal fluid cultures.
Discussion:
A significant proportion (40%) of children with advanced appendicitis had organisms either not susceptible or resistant to our first line antibiotic in their peritoneal fluid cultures. Our clinical pathway now recommends piperacillin-tazobactam as the most effective empiric therapy for advanced appendicitis in children. Microbiologic analysis of peritoneal fluid at appendectomy may be used to tailor antibiotic therapy in advanced appendicitis.
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