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Published on: August 30, 2018
Complicated acute appendicitis in children: the importance of stewarding antibiotic prescriptions
Filippo Ghidini1, Calogero Virgone1, Daniele Donà2
1Pediatric Surgery Unit Department of Women's and Children's Health, Padua University Hospital, Padua.
Insights
The standard three-drug antibiotic regimen for complicated appendicitis has a high failure rate, particularly in extensively complicated cases. New treatment protocols are recommended for better outcomes in these patients.
Area of Science:
- Infectious Diseases
- Surgical Infections
- Pharmacology
Background:
- Complicated appendicitis requires effective antimicrobial treatment.
- A three-drug regimen (cefazoline, metronidazole, gentamicine) was assessed for efficacy.
- Predictors of treatment failure were investigated.
Purpose of the Study:
- To evaluate the success rate of a three-drug antibiotic regimen for complicated appendicitis.
- To identify factors predicting treatment failure in complicated appendicitis.
Main Methods:
- Retrospective study of patients with complicated appendicitis (2013-2018).
- Patients categorized into localized complicated appendicitis (LCA) and extensively complicated appendicitis (ECA).
- Failure defined as a shift to second-line antibiotics due to clinical deterioration; univariate and multivariate analyses performed.
Main Results:
- The three-drug regimen failed in 36% of patients, with a higher failure rate in the ECA group (50%).
- Extensively complicated appendicitis (ECA) was a significant predictor of failure (adjusted OR 3.00).
- ECA patients had longer hospital stays and antimicrobial therapy durations, but similar surgical site infection rates.
Conclusions:
- The current three-drug regimen exhibits a high failure rate for complicated appendicitis.
- A new antibiotic protocol is advised, especially for patients with extensively complicated appendicitis (ECA).
- Antibiotic stewardship programs should consider these findings for updated treatment guidelines.
Background:
The aim was to assess the success of a three-drug regimen, consisting of cefazoline, metronidazole and gentamicine, for the antimicrobial treatment of complicated appendicitis and to investigate predictors of failure.
Methods:
This retrospective study included patients who had undergone appendectomy for complicated appendicitis from 2013 to 2018. The shift to second-line antibiotics was considered a failure. The choice was based upon clinical deterioration. Patients were grouped into 2 groups: localized complicated appendicitis (LCA) and extensively complicated appendicitis (ECA) for the study purpose. Univariate and multivariate analysis were performed to identify predictors of failure.
Results:
Ninety patients (65.2%) with LCA and 48 patients (35%) with ECA were included. Three-drug regimen failed in 50 patients (36%) with a higher rate in the ECA group (50%, p=0.017). In a multivariate analysis, this failure was found to be associated with ECA (adjusted OR 3.00 [1.2-7.4], p=0.041). Children with ECA experienced a longer hospital stay (median length 8 days, p < 0.001) and antimicrobial therapy (median length 8 days, p < 0.001). However, no difference in the rate of surgical site infections was found (p=0.514).
Conclusions:
The institutional antibiotic stewardship program highlighted a high failure rate for the old threedrug regimen. A new protocol should be recommended, especially for the patients affected by ECA.
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