Presenter Status

Fellow

Abstract Type

Research

Primary Mentor

Tolulope A Oyetunji, MD

Start Date

10-5-2023 11:30 AM

End Date

10-5-2023 1:30 PM

Presentation Type

Abstract

Description

Background: The optimal antibiotic regimen in perforated appendicitis to reduce intraabdominal abscess (IAA) formation has not yet been agreed upon in the pediatric surgery community. We aimed to evaluate the outcomes of patients with perforated appendicitis when intravenous antibiotic monotherapy with Piperacillin-Tazobactam (PT) versus dual-drug therapy with Ceftriaxone and Metronidazole (CM) are administered. We hypothesized there is no difference in the rate of IAA formation with antibiotic monotherapy, as opposed to our once-daily dosed, institutional standard dual-drug therapy.

Objectives/Goal: The goal was to determine if our current management protocols for acute appendicitis were delivering the best possible results for our patients. The primary outcome was 30-day postoperative IAA formation.

Methods/Design: A single institution retrospective cohort study of children <18 years old with perforated appendicitis from October 2019 to March 2020 and October 2021 to May 2022 at a freestanding pediatric hospital. These study periods represent the only periods where PT was administered due to CM shortages or for the purposes of research studies. CM was administered once daily, with dosing of ceftriaxone as 50 mg/kg with a maximum dose of 2000 mg and metronidazole 30 mg/kg with a maximum dose of 1500 mg. PT was administered in a weight- based fashion with patients weighing <40 kg receiving 100 mg/kg Q8HR and those >40 kg receiving 3000 mg Q6HR.

Results: One hundred and seventeen patients were identified during the study periods: 65.8% (N=77) in the CM group and 34.2% (N=40) in the PT group. No differences in median [IQR] age 10.9 years [7.4,13.4] vs 10.4 years [7.5,12.5] (P=0.8), body mass index 19.7 kg/m2 [16.8,23.1] vs 19.5 kg/m2 [17.3,23.2] (P=0.1) or duration of symptoms 2 days [2,3] vs 2 days [2,3] (P=0.9) were identified. All patients underwent three port laparoscopic appendectomy. There were no intraoperative complications identified in either group or conversions to open appendectomy. Transfer from regional institutions occurred in 59.8% (N=70) patients. Crossover of antibiotic administration occurred in 28.6% (N=22) of the CM group and 40% (N=16) of the PT group preoperatively and prior to transfer. There were no differences between the CM and PT groups in postoperative median [IQR] length of stay (LOS) 3.2 days [3.1, 3.8] vs 3.3 days [3.1, 4.0] (P=0.1) or median [IQR] duration of intravenous antibiotic treatment 3.2 days [3.1, 3.8] vs 3.3 days [3.1, 3.5] (P=0.2). Compared to the PT group, those in the CM group had a lower IAA rate (13% vs 20%, P=0.32) and fewer post discharge emergency room visits (14.3% vs 27.5%, P=0.08). Table 1. Multivariate logistic regression analysis did not find antibiotic choice to be a significant predictor for developing intra-abdominal abscess [OR 1.78, P = 0.21]. Table 2.

Conclusions: This retrospective study suggests that our postoperative dual-drug antibiotic regimen of CM is equivalent to broad-spectrum, single-drug therapy with PT with regards to IAA formation, post-operative ED visits, total hospital LOS and wound complications.

MeSH Keywords

antibiotic regimen; children; perforated appendicitis

Additional Files

1339-Shai Stewart-Abstract.pdf (227 kB)
Abstract

COinS
 
May 10th, 11:30 AM May 10th, 1:30 PM

Antibiotic Monotherapy vs Dual-Drug Therapy in Perforated Appendicitis: Single Center Retrospective Review

Background: The optimal antibiotic regimen in perforated appendicitis to reduce intraabdominal abscess (IAA) formation has not yet been agreed upon in the pediatric surgery community. We aimed to evaluate the outcomes of patients with perforated appendicitis when intravenous antibiotic monotherapy with Piperacillin-Tazobactam (PT) versus dual-drug therapy with Ceftriaxone and Metronidazole (CM) are administered. We hypothesized there is no difference in the rate of IAA formation with antibiotic monotherapy, as opposed to our once-daily dosed, institutional standard dual-drug therapy.

Objectives/Goal: The goal was to determine if our current management protocols for acute appendicitis were delivering the best possible results for our patients. The primary outcome was 30-day postoperative IAA formation.

Methods/Design: A single institution retrospective cohort study of children <18 years old with perforated appendicitis from October 2019 to March 2020 and October 2021 to May 2022 at a freestanding pediatric hospital. These study periods represent the only periods where PT was administered due to CM shortages or for the purposes of research studies. CM was administered once>daily, with dosing of ceftriaxone as 50 mg/kg with a maximum dose of 2000 mg and metronidazole 30 mg/kg with a maximum dose of 1500 mg. PT was administered in a weight- based fashion with patients weighing <40 kg receiving 100 mg>/kg Q8HR and those >40 kg receiving 3000 mg Q6HR.

Results: One hundred and seventeen patients were identified during the study periods: 65.8% (N=77) in the CM group and 34.2% (N=40) in the PT group. No differences in median [IQR] age 10.9 years [7.4,13.4] vs 10.4 years [7.5,12.5] (P=0.8), body mass index 19.7 kg/m2 [16.8,23.1] vs 19.5 kg/m2 [17.3,23.2] (P=0.1) or duration of symptoms 2 days [2,3] vs 2 days [2,3] (P=0.9) were identified. All patients underwent three port laparoscopic appendectomy. There were no intraoperative complications identified in either group or conversions to open appendectomy. Transfer from regional institutions occurred in 59.8% (N=70) patients. Crossover of antibiotic administration occurred in 28.6% (N=22) of the CM group and 40% (N=16) of the PT group preoperatively and prior to transfer. There were no differences between the CM and PT groups in postoperative median [IQR] length of stay (LOS) 3.2 days [3.1, 3.8] vs 3.3 days [3.1, 4.0] (P=0.1) or median [IQR] duration of intravenous antibiotic treatment 3.2 days [3.1, 3.8] vs 3.3 days [3.1, 3.5] (P=0.2). Compared to the PT group, those in the CM group had a lower IAA rate (13% vs 20%, P=0.32) and fewer post discharge emergency room visits (14.3% vs 27.5%, P=0.08). Table 1. Multivariate logistic regression analysis did not find antibiotic choice to be a significant predictor for developing intra-abdominal abscess [OR 1.78, P = 0.21]. Table 2.

Conclusions: This retrospective study suggests that our postoperative dual-drug antibiotic regimen of CM is equivalent to broad-spectrum, single-drug therapy with PT with regards to IAA formation, post-operative ED visits, total hospital LOS and wound complications.