Download - Catalyst

Antibiotics in the Management of
Acute Appendicitis.
Pediatric Surgery
January 3, 2013
Cameron Gaskill
Objectives
M&M Case
Infectious Complications
Early Appendicitis
- Antibiotics
- Surgical timing
- Same day discharge
Perforated Appendicitis
- Preoperative antibiotics
- Postoperative antibiotics; regimen, timing
M&M Case
DJC (1251768) 7yo Male, presented to ED with 3 day history of
abdominal pain.
Leukocytosis to 26,700, Fever to 40.4
Underwent laparoscopic appendectomy on 12/10/12.
- Intraoperative findings: appendiceal perforation with gross
purulent material in pelvis
Admitted to General Surgery floor on IV Zosyn.
M&M Case
POD 1: NG removed, afebrile
POD 2: Foley removed, Tolerating regular diet
POD 3: Transitioned to PO pain regimen
POD 5: Discharged, WBC 7.6. Final day of IV Zosyn
PO antibiotics not continued at discharge
M&M Case
POD 8: Telephone discharge call: No pain or complaints.
POD 10: GS clinic follow up
- 0/10 pain on questioning
- Required assistance getting on exam table, limping gait.
- Febrile to 38.7, Leukocytosis to 21,000
- CT abd/pelvis: RLQ pelvic abscess 2.1x2.8x3.3cm
- Readmitted to General Surgery floor, restarted on IV Zosyn
M&M Case
POD 11: IR percutaneous drain placed, drain output 71mL, afebrile
POD 12: PICC placed, IR drain output 25ml
POD 13: Discharged home
- IR drain output 10ml
- Leukocytosis 5,300
- IV ceftriaxone/metronidazole; to complete 14 day total
POD 15: Telephone discharge call: No pain or complaints.
Objectives
M&M Case
Infectious Complications
Early Appendicitis
- Antibiotics
- Surgical timing
- Same day discharge
Perforated Appendicitis
- Preoperative antibiotics
- Postoperative antibiotics; regimen, timing
Infectious Complications
Increased risk in advanced appendicitis
Wound infection: 2-9%
- Treated by local drainage
Intraabdominal abscess: 5%
- Persistent fever, abdominal pain, delayed PO intake POD5-7
- Treated with prolonged IV antibiotic course,
percutaneous drainage
Early Appendicitis: Antibiotics
single prophylactic dose of a broad spectrum antibiotics
ei. cefoxitin, zosyn, cefotetan, ceftriaxone & metronidazole
Cochrane Review 2005: meta analysis of 45 trials.
Antibiotics vs. Placebo.
-wound infections (5 versus 11 percent)
-intraabdominal abscesses (0.6 versus 1.4 percent)
Early Appendicitis: Surgical timing
2004 Jour of Ped Surg: Retrospective, 126 patients
- Operate within 2-6 hours vs within 24h
- All received appropriate preoperative antibiotics
- No difference in perforation, complication, or operating time
Same day discharge
2012 Arch Surg: Prospective study, 186 children early appendicitis.
- 87% discharged on day of surgery.
- All received single dose preoperative antibiotic
- Complications:
Minor: 8%,
Urgent revisits: 7%
Readmissions: 2.5%.
Perforated Appendicitis:
Preoperative Antibiotics
- Supported by 2005 Cochrane Review
- American Pediatric Surgical Association recommend Zosyn
- Initial dose within 30 to 60 minutes prior to operation.
Perforated Appendicitis:
Postoperative antibiotics
Perforated Appendicitis:
Postoperative antibiotics
Triple versus single drug therapy
Perforated Appendicitis:
Postoperative antibiotics - Duration
“Limiting duration of antibiotic use
to 3 days did not appear to be
associated with higher rates of
intraabdominal abscess or wound
infection.”
Perforated Appendicitis:
Postoperative antibiotics - Duration
Randomized Control Trial, 102 patients.
- IV x 5 days vs. discharge home on PO to complete total 7 days.
- Discharge criteria: Tolerating PO, afebrile x12hours
- No difference in intraabdominal abscess (19% vs 20%)
- Decreased LOS in IV/PO group (6 vs 4.4, p<0.01)
Perforated Appendicitis:
Postoperative antibiotics
Recommendations:
Preoperative antibiotics: Grade A
Post operative single antibiotic therapy: Grade B
IV antibiotic duration determined by clinical criteria: Grade B
PO antibiotics to supplement shorter IV duration: Grade B
Perforated Appendicitis:
Postoperative antibiotics
Study in progress: IV antibiotics until clinically well.
- discharged without PO antibiotics if WBC normal
vs with PO antibiotics to complete 7 day course.