Adherence to Preoperative Ceftriaxone and Metronidazole Improves Outcomes in Acute Appendicitis

Acute appendicitis is the most common pediatric surgical emergency, with approximately 70 000 cases annually in the United States. Preoperative antibiotic regimens vary widely. Prior to 2024, our institution used cefoxitin or meropenem based on perceived perforation status. To align with evidence supporting narrow-spectrum regimens, we implemented a standardized antibiotic protocol, aiming to increase use of recommended first-line preoperative antibiotics-intravenous ceftriaxone and metronidazole (CRO-MTZ)-for pediatric emergency department (PED) patients undergoing appendectomy for acute appendicitis from 0% to 75% within 8 months.

Our "Appendicitis Antibiotic Bundle" interventions included targeted education, pathway revision, and electronic health record updates. The primary measure was administration of CRO-MTZ. Secondary measures included preoperative antipseudomonal antibiotic use and antibiotic cost. Balancing measures were PED and hospital length of stay (LOS) and surgical site infections (SSIs). Statistical process control methods were used for analysis. We evaluated measures for both PED and all appendicitis patients, including those transferred from other facilities.

Administration of CRO-MTZ increased from 0% to 86% for PED and to 77% for all appendicitis patients. Preoperative antipseudomonal antibiotic use decreased from 19.1% to 5.5% in PED patients. The hospital-wide appendicitis SSI rate declined from 4.0% to 1.4%. There was a 21% decrease in preoperative antibiotic costs, a 25-minute reduction in PED LOS, and a 9.9-hour reduction in hospital LOS. All measures achieved special cause variation.

Associated with standardizing preoperative antibiotics for acute appendicitis, we noted reduced broad-spectrum antibiotic use and cost without increasing SSIs or LOS.