Switching lanes: No home antibiotics or laboratory testing prior to discharge in perforated appendicitis

Appendicitis is the most common surgical emergency in children with approximately 30 % of patients presenting with perforation, defined as a hole in the appendix or a fecalith found in the abdomen, at time of surgery. Our previous protocol at time of discharge, with an 8 % intra-abdominal abscess (IAA) rate, included checking a white blood cell count (WBC) on day of discharge, with a value ≥ 10 serving as a trigger for additional outpatient oral antibiotics course. Beginning in May, 2023 we changed our protocol to no longer obtain WBC count or prescribe outpatient antibiotics at time of discharge. The purpose of this study is to determine if the post-discharge IAA rate of patients with perforated appendicitis was impacted with no antibiotics at discharge.

A prospective observational study of patients <18 years old who underwent laparoscopic appendectomy for perforated appendicitis between May 1, 2023-May 1, 2024 at a single institution was completed. Patients were treated with antibiotics while inpatient and then discharged without antibiotics once appropriate discharge criteria were met (pain controlled, afebrile ≥12 h, and tolerating regular diet).

A total of 202 patients were managed for perforated appendicitis since the protocol change. The median LOS for the entire cohort was 3.02 days (IQR 2.11, 4.21). 9.9 % of patients (N = 20) developed IAA after discharge, 15 (7 %) of which were readmitted. Median LOS for these patients was 2.81 days (2.49, 3.32) compared to median LOS of 3.03 days (2.12, 4.22) (p = 0.65). Eight patients (4 %) underwent percutaneous drainage with interventional radiology (IR). Patients who developed IAA after discharge had longer operative times (52 min vs 40 min, p = 0.01). There was no significant difference in age, BMI, LOS, antibiotic duration, or presenting symptoms for patients that developed IAA compared to those that did not develop IAA. Under the context of a one-tailed non-inferiority study with a non-inferiority margin of 12 % and our given sample size for the two groups (power = 0.801, alpha = 0.025), the difference in post-operative IAA rates between the two groups is 2 % (95 % CI: -2 %-7 %), concluding that withholding antibiotics at discharge is non-inferior.

Omission of outpatient antibiotics and pre-discharge laboratory testing did not result in a significant change in post-operative IAA rate after discharge.

IV, Prospective observational study.