1. Antibiotics in the Management of Acute Appendicitis. Pediatric Surgery Cameron Gaskill January 3, 2013

2. Objectives M&M Case Infectious Complications Early Appendicitis - Antibiotics - Surgical timing - Same day discharge Perforated Appendicitis - Preoperative antibiotics - Postoperative antibiotics; regimen, timing

3. 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.

4. 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

5. 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

7. 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.

8. Objectives M&M Case Infectious Complications Early Appendicitis - Antibiotics - Surgical timing - Same day discharge Perforated Appendicitis - Preoperative antibiotics - Postoperative antibiotics; regimen, timing

9. 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

10. 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)

11. Early Appendicitis: Surgical timing Same day discharge 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 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%.

12. 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.

13. Perforated Appendicitis: Postoperative antibiotics

14. Perforated Appendicitis: Postoperative antibiotics Triple versus single drug therapy

15. 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.”

16. 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)

17. 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

18. 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.