Improving Antibiotic Stewardship in Acute Appendicitis through Risk-Based Empiric Treatment Selection

Empiric antimicrobial treatment selection for management of appendicitis is based on patient risk of infection with drug-resistant pathogens. Per Surgical Infection Society (SIS) guidelines, only high-risk patients should receive extended spectrum antibiotics. After observing substantial use of piperacillin-tazobactam at an academic medical center, a quality improvement initiative was developed targeting standardization of antibiotics for uncomplicated appendicitis. A project was performed to improve antibiotic stewardship in acute appendicitis treatment using plan-do-study-act methodology. We designed educational materials to guide risk-based empiric antimicrobial treatment selection for adult patients presenting with appendicitis. Implementation began January 1, 2020. High-risk criteria included presence of sepsis, presence of one or more comorbidities, and health-care-associated appendicitis. Retrospective chart review included adult patients admitted for appendectomy between January 1, 2019 and December 1, 2020. Pre-/post-implementation analysis and run chart analysis were performed. Primary outcome was the proportion of patients receiving the correct antibiotic. Secondary outcomes included antibiotic cost. Patients treated pre-/post-implementation were compared using univariable analysis, with statistical significance set at p < 0.05. Of the 138 patients, 85 patients were in the pre-implementation group and 53 in the implementation group. The implementation group was 19.1% more likely to receive the correct antibiotic (pre = 31.8%; post = 50.9%; p = 0.03). Average cost per patient was reduced $13.25 (pre = $23.68 ± $18.76; post = $10.43 ± $8.45; p ≤ 0.0001). There were no differences in complications (pre = 2.4%; post = 0%; p = 0.26) or re-admissions (pre = 2.34%; post = 1.9%; p = 0.86). After an educational initiative to raise awareness about SIS guidelines for empiric antibiotic treatment for acute appendicitis, we observed an increase in the number of patients receiving the appropriate antibiotic. Prescribing habits were altered with no adverse impact on clinical outcomes. The next phase will address sustainability by incorporating an electronic medical record order set to integrate just-in-time education within the provider workflow.