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The intraperitoneal bacteriology and antimicrobial resistance in acute appendicitis among children: a retrospective
Halima Dabaja-Younis1, Hanna Farah2, Ran Miron2
1Pediatric Infectious Disease Unit, Ruth Rappaport Children's Hospital, Rambam Healthcare Center, P.O. Box 9602, 31096, Haifa, Israel. h_dabaja@rambam.health.gov.il.
Insights
The study found an increasing rate of Gram-positive cocci, especially Milleri group Streptococci, in complicated appendicitis. This trend is linked to more severe disease, longer hospital stays, and higher readmission rates, highlighting the need for anti-Gram-positive antibiotics.
Area of Science:
- Microbiology
- Pediatric Surgery
- Infectious Diseases
Background:
- Gram-negative rods traditionally dominate intraperitoneal flora in complicated appendicitis.
- Antibiotic selection for complicated appendicitis remains challenging due to evolving resistance patterns.
Purpose of the Study:
- To investigate the changing microbiology of intraperitoneal flora in pediatric complicated appendicitis.
- To describe the susceptibility profile of isolated pathogens.
- To correlate specific microbial findings with clinical outcomes.
Main Methods:
- Retrospective cohort study of 1466 children (<18 years) with pathologically confirmed appendicitis (2007-2017).
- Analysis of intraperitoneal fluid cultures from 655 patients.
- Microbiological identification and antimicrobial susceptibility testing.
Main Results:
- Gram-negative rods were the most common isolates (67.6%), followed by Gram-positive cocci (21.5%).
- The proportion of Milleri group Streptococci among Gram-positive cocci significantly increased from 9.5% to 56.3%.
- Patients with Gram-positive cocci showed longer hospital stays and more complicated disease; Milleri group Streptococci was associated with higher readmission rates.
Conclusions:
- There is a notable increase in Gram-positive cocci, particularly Milleri group Streptococci, in the peritoneal fluid of children with complicated appendicitis.
- The rise in Gram-positive isolates correlates with adverse clinical outcomes, including disease severity and hospital length of stay.
- These findings underscore the importance of considering anti-Gram-positive antimicrobial agents in treatment regimens for complicated appendicitis.
Abstract:
This study aims to describe the microbiology and susceptibility profile of the intraperitoneal flora in complicated appendicitis. It is a retrospective cohort study including children < 18-year-old with pathologically confirmed appendicitis, from 2007 to 2017. It included 1466 children. Intraperitoneal samples were obtained from 655 (44.7%) patients, and 201 (30.7%) had positive culture with 395 pathogens. Gram-negative rods comprised 67.6%, Gram-positive cocci 21.5%, and anaerobes 10.9% of the isolates. Gram-positive cocci were detected in 67 (37.8%) patients. Milleri group Streptococci was the most frequently isolated Gram-positive (44.7%). The proportional rate of Milleri group Streptococci from Gram-positive cocci increased from 9.5 to 56.3% (P < 0.001, OR 12.214). Patients with Gram-positive cocci had longer hospital stay (mean 9.36 + 6.385 vs 7.72 + 4.582, P = 0.036, (CI -3.165, -0.105)) and more complicated disease (89.5% vs 78.4%, P = 0.045, OR 2.342). Patients with Milleri group Streptococci isolates readmitted more frequently (26.5% vs 13.2%, P = 0.05, OR 2.37). Resistance to amoxicillin-clavulanate, gentamicin, ceftazidime, piperacillin-tazobactam, and amikacin were detected in 29.1%, 6.5%, 2.3%, 1.2%, and 0.7% of the Gram-negative rods, respectively.Conclusion: The rates of Gram-positive cocci and particularly Milleri group Streptococci in peritoneal fluid are increasing. More complicated disease and longer hospital stay in Gram-positive cocci and higher readmission rate in Milleri group Streptococci. These emphasize the role of anti-Gram-positive antimicrobials. What is known: • Gram-negative rods are the main isolates in complicated appendicitis. • The choice of antibiotic regimen is an unsettled issue due to resistance. What is new: • Increased rate of Gram-positive cocci and Milleri group Streptococci. • More complicated disease, longer hospital stay, and higher readmission rate.
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