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PNG Med J 2012 Mar-Dec;55(1-4):12-15 The bacterial flora of acute appendicitis at the Port Moresby General Hospital in Papua New Guinea Damien J. Hasola1,2, Ray Dutta3, Cecil Darrell3, George Gende1, William Kaptigau1, Osborne Liko1 and Ikau Kevau1 Surgery Department and Pathology and Microbiology Department, Port Moresby General Hospital, Papua New Guinea sUmmary Acute appendicitis is a common cause of acute abdomen requiring an emergency appendicectomy. Complications such as perforation and peritoneal contamination leading to peritonitis can result from delay in presentation and an emergency operation. This study prospectively recruited 101 patients diagnosed with acute appendicitis to correlate the bacterial flora with the severity of appendicitis. The results show that 90 patients had acutely inflamed or gangrenous appendicitis and 11 had perforated appendicitis. The ages ranged from 6 to 49 years with a median of 20 years. There were 59 females and 42 males. The commonest isolates were aerobic bacteria such as Escherichia coli, Group D streptococci and Klebsiella pneumoniae. Mixed infection with anaerobes such as Bacteroides fragilis was seen only in perforated appendicitis. The best choices of antibiotic were a fluoroquinolone, cephalosporin and aminoglycoside for aerobic organisms and metronidazole for anaerobes. Introduction initiates but at present this is only speculative (1). Appendicitis is a disease of antiquity but acquired prominence when it was recognized as a clinical and pathological entity requiring surgical therapy in 1886. Before this in the 16th century it was known as perityphlitis, a ‘fatal suppurative disease of the caecal region’ (1). It was only as recently as 1938 that bacterial infection was documented by Altemeier in appendicitis (2). Since then it is known that from 4 to 10 different species which act in synergism can be isolated. Most studies (2-5) show that bacterial invasion is secondary and that the isolates are mainly Escherichia coli, streptococci groups and Bacteroides fragilis. The basic pathological process in appendicitis is obstruction, usually by a faecolith. The progressive nature of the inflammation results from a sudden rise in intraluminal hydrostatic pressure with vascular obstruction and bacterial invasion of the appendicular wall. Perforation occurs at the weakest point, which is at the antimesenteric border. There are other intriguing causes such as orange seeds, ascarids and pins that have lodged themselves in the caecal appendix but they are extremely rare. The equivalent of the Peyer’s patches in the appendix has been suggested as the place where the process In Papua New Guinea no such study has been done to date to establish the microbiology of appendicitis. The aim of this study was to establish the bacterial profile in acute appendicitis and the antibiotic susceptibilities of the bacteria and to correlate these findings with the severity of the disease. Materials and Methods 101 patients with clinical and histologically proven acute appendicitis were recruited into 1 S urgery Department, Port Moresby General Hospital, Free Mail Bag, Boroko, National Capital District 111, Papua New Guinea 2 P resent address: Department of General Surgery, Buka General Hospital, Autonomous Region of Bougainville [email protected] 3 P athology and Microbiology Department, Port Moresby General Hospital, Free Mail Bag, Boroko, National Capital District 111, Papua New Guinea 12 Papua New Guinea Medical Journal Volume 55, No 1-4, Mar-Dec 2012 incubated at 36-37°C for 48 hours under aerobic and anaerobic conditions with anaerobic gas pack for another 48 hours. Positive colonies were Gram stained and any Gram-negative rods were tested against metronidazole and gentamicin discs. The first subculture after 48 hours on to MacConkey agar was incubated in an aerobic environment at 35-37°C for 18-48 hours. Positive colonies were Gram stained and tested using the Analytical Profile Index (API – Oxide bioMérieux Inc, USA) to identify the different isolates. the study. All patients were operated on at the Port Moresby General Hospital from March to December 2009. Before operation antibiotics effective against both aerobic and anaerobic organisms were routinely given. Under general anaesthesia, the appendicectomies were mainly done through a Lanz incision except for patients with peritonitis who had lower midline laparotomies. Once the abdomen had been opened the diseased appendix was amputated and any pus or fibrin sucked out. The peritoneal cavity was copiously irrigated with normal saline and the wound repaired in layers. The layers of skin were approximated loosely or left open if pus was present and closed by secondary intention. Results Of the 101 patients 59 were females and 42 were males. The youngest was 6 years old and the oldest 49 years with a median of 20 years. The duration of illness to the day of operation ranged from 2 to 6 days with an average of 3 days. 50 patients had acutely inflamed appendicitis, 40 had gangrenous appendicitis and 11 had perforated appendicitis (Table 1). There were no deaths in this series; however, one patient had a residual abscess that was drained and improved. Specimen procurement The appendix was divided into halves without entering the lumen. One half was sent for histological diagnosis and the other for bacteriological culture. The tissue for culture was mashed using a sterile plate. Immediately it was placed in Robertson’s cooked medium (enriched medium) and sealed with an airtight cap. In the laboratory the samples were table 1 Aerobic and anaerobic bacteria cultured from early, gangrenous and perforated appendicitis Bacteria Early appendicitis n = 50 Gangrenous appendicitis n = 40 Perforated appendicitis n = 11 Total 29 40 11 80 Group D streptococci 3 7 10 20 Klebsiella pneumoniae 3 3 5 11 Citrobacter freundii 1 1 6 8 Proteus mirabilis 1 1 2 4 0 0 3 3 Aerobic (123) Escherichia coli Anaerobic (3) Bacteroides fragilis 13 2/4 (50%) 4 Proteus mirabilis 14 nt = not tested Total Bacteroides fragilis 126 nt 7/8 (88%) 8 Citrobacter freundii 3 2/11 (18%) 11 Klebsiella pneumoniae Anaerobic (3) 15/20 (75%) 20 Group D streptococci 33/80 (41%) Amoxycillin 80 Number of strains Escherichia coli Aerobic (123) Bacteria nt 3/4 (75%) 7/8 (88%) 8/11 (73%) 19/20 (95%) 61/80 (76%) Chloramphenicol 0/3 (0%) 3/4 (75%) 8/8 (100%) 11/11 (100%) 15/20 (75%) 76/80 (95%) Gentamicin nt 3/4 (75%) 8/8 (100%) 11/11 (100%) 19/20 (95%) 78/80 (98%) Ceftriaxone nt 4/4 (100%) 8/8 (100%) 11/11 (100%) 20/20 (100%) 80/80 (100%) Ciprofloxacin 3/3 (100%) Metronidazole The antibiotic susceptibility patterns of isolates from acute appendicitis at Port Moresby General Hospital in 2009 Table 2 Papua New Guinea Medical Journal Volume 55, No 1-4, Mar-Dec 2012 Papua New Guinea Medical Journal Volume 55, No 1-4, Mar-Dec 2012 a reflection of lengthy exposure to many antibiotics over time (7). Metronidazole has been shown to reduce mortality and morbidity from appendicitis and has become the main prophylactic antibiotic in appendicitis. The further isolation of Bacteroides species depends on the laboratory’s capacity to culture and identify them. Pseudomonas species were not seen in our study but were predominant in western studies, which is hard to explain. Our findings suggest that there are serious levels of resistance against commonly used antibiotics in the community. Since this is the first study for our hospital it will need to be repeated in the future to monitor resistance levels for site-specific diseases such as appendicitis, osteomyelitis and pyelonephritis. The 126 bacterial isolates showed an upward trend in colonization both qualitatively and quantitatively as the disease worsened. Escherichia coli, Group D streptococci and Klebsiella pneumoniae accounted for 90% of aerobic isolates whereas Bacteroides fragilis was isolated from 3 patients with perforated appendicitis (Table 1). Bacterial susceptibilities showed a variable pattern of resistance to commonly used antibiotics ranging from 0 to 82% (Table 2) in the aerobic pathogens group. All aerobic organisms were susceptible to ciprofloxacin. In the anaerobic group, B. fragilis was completely susceptible to metronidazole. Discussion In conclusion, a cephalosporin or gentamicin combined with metronidazole should be the first choice for antibiotic therapy in appendicitis. Ciprofloxacin should be reserved for cases not responding to cephalosporin or an aminoglycoside. The emergency operation should be done the same day by a trained surgeon to get optimum results in our setting. It is also important to have a hospital policy so that there is a protocol for prescribing antibiotics that is based on the organisms likely to be found and their antibiotic resistance levels rather than ‘best guess’. This study showed that a mixed infection exists, with aerobic bacteria predominating in early infection and anaerobic bacteria appearing in late complicated appendicitis. E. coli, Group D streptococci, K. pneumoniae and Citrobacter freundii accounted for 97% of aerobic bacteria in early acute appendicitis. This study affirms the position of B. fragilis in perforated appendicitis. The antibiotics of first choice are a fluoroquinolone, cephalosporin and aminoglycoside for aerobic organisms and metronidazole for anaerobes. Although there was no mortality in this study, 1 case of post-appendicectomy residual abscess in a perforated appendicitis was seen. Complications were reduced because of a tendency to early operation, copious peritoneal saline wash and antibiotic therapy including metronidazole (6). Community-acquired appendicitis from E. coli, K. pneumoniae and streptococci had a high level of resistance to the commonly used antibiotics such as chloramphenicol and penicillins. This may be due to indiscriminate prescription patterns in Papua New Guinea. references 1 Williams NS, Bulstrode CJK, O’Connell PR, eds. Bailey and Love’s Short Practice of Surgery. Twentyfifth edition. London: Hodder Arnold, 2008. 2 Altemeier WA. The bacterial flora of acute perforated appendicitis with peritonitis: a bacteriologic study based upon one hundred cases. Ann Surg 1938;107:517-528. 3 Bennion RS, Baron EJ, Thompson JE Jr, Downes J, Summanen P, Talan DA, Finegold SM. The bacteriology of gangrenous and perforated appendicitis – revisited. Ann Surg 1990;211:165-171. 4 Roberts JP. Quantitative bacterial flora of acute appendicitis. Arch Dis Child 1988;63:536-540. 5 Brook I. Bacterial studies of peritoneal cavity and postoperative surgical wound drainage following perforated appendix in children. Ann Surg 1980;192:208-212. 6 Pinto DJ, Sanderson PJ. Rational use of antibiotic therapy after appendicectomy. Br Med J 1980;280:275–277. 7 Berne TV, Yellin AE, Appleman MD, Gill MA, Chenella FC, Heseltine PN. Surgically treated gangrenous or perforated appendicitis: a comparison of aztreonam and clindamycin versus gentamicin and clindamycin. Ann Surg 1987;205:133-137. The emergence of multiple drug resistance in bacteria appears to be a formidable challenge to our hospitals. Our findings are supported by other studies in both the qualitative and quantitative nature of the bacteria isolated; however, they differ with respect to the antibiotics used (3,4,6). It is probable that the use of clindamycin and gentamicin as the antibiotics of choice is 15