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Comparative Effectiveness of Ceftriaxone plus Metronidazole versus Anti-Pseudomonal Antibiotics for Perforated
Rana F Hamdy1, Lori K Handy2, Evangelos Spyridakis2
11 Department of Pediatrics, Children's National Health System, Washington, DC.
Insights
For perforated appendicitis in children, initial antibiotic choice did not significantly impact post-operative complications. Both ceftriaxone plus metronidazole (CTX/MTZ) and broader-spectrum anti-pseudomonal regimens showed similar complication rates.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
- Pharmacology
Background:
- Appendicitis is a leading cause of pediatric surgical emergencies and antibiotic use.
- Optimal antibiotic selection for perforated appendicitis in children remains undetermined.
- Current practices vary significantly among children's hospitals.
Purpose of the Study:
- To compare the efficacy of two initial antibiotic regimens for perforated appendicitis in children.
- To evaluate post-operative complications associated with ceftriaxone plus metronidazole (CTX/MTZ) versus anti-pseudomonal agents.
- To inform antibiotic stewardship in pediatric surgical care.
Main Methods:
- Retrospective cohort study of 353 children undergoing surgery for perforated appendicitis (January 2011-March 2015).
- Comparison of initial antibiotic regimens: CTX/MTZ versus anti-pseudomonal drugs (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, meropenem).
- Primary outcome: post-operative complications (incisional infection or abscess) within six weeks of discharge. Excluded specific patient groups.
Main Results:
- Post-operative complications occurred in 14.7% of the CTX/MTZ group and 17.8% of the anti-pseudomonal group (p=0.32).
- Antibiotic-related complications were 4.4% for CTX/MTZ and 6.9% for anti-pseudomonal regimens.
- Multivariable analysis showed no significant difference in complication odds (aOR 1.25; 95% CI 0.66-2.40) between the groups.
Conclusions:
- Initial antibiotic regimens of CTX/MTZ or broader-spectrum anti-pseudomonal drugs yield similar post-operative complication rates in pediatric perforated appendicitis.
- Findings support current antibiotic choices but highlight the need for further research into optimal treatment strategies.
- This study contributes to evidence-based guidelines for managing perforated appendicitis in pediatric patients.
Abstract:
Appendicitis is the most common pediatric surgical emergency and one of the most common indications for antibiotic use in hospitalized children. The antibiotic choice differs widely across children's hospitals, and the optimal regimen for perforated appendicitis remains unclear. We conducted a retrospective cohort study comparing initial antibiotic regimens for perforated appendicitis at a large tertiary-care children's hospital. Children hospitalized between January 2011 and March 2015 who underwent surgery for perforated appendicitis were identified by ICD-9 codes with confirmation by chart review. Patients were excluded if they had been admitted ≥48 hours prior to diagnosis, had a history of appendicitis, received inotropic agents, were immunocompromised, or were given an antibiotic regimen other than ceftriaxone plus metronidazole (CTX/MTZ) or an anti-pseudomonal drug (cefepime, piperacillin/tazobactam, ciprofloxacin, imipenem, or meropenem) within the first two days after diagnosis. The primary outcome of interest was post-operative complications, defined as development of an incisional infection or abscess within six weeks of hospital discharge. Of the 353 children who met the inclusion criteria, 252 (71%) received CTX/MTZ and the others received an anti-pseudomonal regimen. A post-operative complication occurred in 37 (14.7%) of the CTX/MTZ group versus 18 (17.8%) of the anti-pseudomonal group. Antibiotic-related complications occurred in 4.4% of children on CTX/MTZ and 6.9% of children on anti-pseudomonal antibiotics (p = 0.32). In a multivariable logistic regression model adjusting for sex, age, ethnicity, and duration of symptoms prior to presentation, the adjusted odds ratio for post-operative complications in children receiving anti-pseudomonal antibiotics was 1.25 (95% confidence interval 0.66-2.40). Post-operative complication rates did not differ for children treated with CTX/MTZ versus a broader-spectrum regimen.
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