1. The Health Roundtable Postoperative IV Antibiotic Therapy for Children with Complicated Appendicitis: A Propensity Score-Matched Observational Study Presenter: Tzu-Chieh Wendy Yu 1. South Auckland Clinical School, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, NEW ZEALAND 2. Starship Children’s Hospital, Auckland District Health Board, NEW ZEALAND Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1-1c HRT1215-Session_WENDY_YU_ADHB_NZ

2. The Health Roundtable KEY PROBLEM Complicated Appendicitis ( appendicitis with secondary peritonitis) is the most common intra-abdominal infection in children. Traditional postoperative antibiotic regimes have long fixed arbitrary durations (>4 days) leading to unnecessary hospitalisation. More recent research: “.... limiting antibiotic duration to 3 days is unlikely to increase risks of infectious complications.” 2

3. The Health Roundtable AIM OF THIS INNOVATION  Overall: To improve inpatient care of children with complicated appendicitis by optimising postoperative intravenous antibiotic therapy  More specifically, to reduce length of hospital stay without compromising patient care from inadequate treatment  An observational study was conducted to evaluate the efficacy and apparent safety of using a set of clinical criteria to guide duration of postoperative IV antibiotic therapy in children with complicated appendicitis  Propensity scores used to match prospectively observed patients [EXPOSURE COHORT] to retrospectively reviewed historical patients [CONTROL COHORT] 3

4. The Health Roundtable BASELINE DATA  Starship Children’s Hospital, Auckland, New Zealand  47 historical patients, retrospectively reviewed, selected and matching using propensity scores, to form the study CONTROL COHORT  All diagnosed with complicated appendicitis and treated with postoperative antibiotics for minimum 5 days  Length of stay, and frequency and severity of postoperative complications recorded (see subsequent slides) 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED Latest Recommendations: “Duration of antimicrobial therapy for established Intra-abdominal infections be guided by clinical Symptoms and signs of resolving infection.” (Grade B Evidence)  Lee et al. J Pediatr Surg. 2010; 45:2181-5.  Nadler & Gaines. Surg Infect (Larchmt). 2008; 9:75-83.  Solomkin et al. Clin Infect Dis. 2010; 50:133-64. 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED Between August 2011 and February 2012, 47 patients diagnosed with complicated appendicitis were prospectively observed and postoperative IV antibiotics were discontinued once the following clinical criteria were satisfied: Must meet all criteria prior to discontinuation of postoperative antibiotics and hospital discharge: 1. Afebrile (Temp < 38.0°C) for 24 hours 2. Tolerating light diet (2 consecutive meals) 3. Pain controlled with oral analgesia 4. Mobilising independently (if ambulatory) 6

7. EXPOSURE [n=47] CONTROL [n=47] p-value Duration of IV Antibiotic Therapy (median as days; IQR) 3 (2)5 (1)< 0.001 Postoperative Length of Stay during Index Admission (median as nights; IQR) 4 (2)5 (2)0.002 Length of Stay during Index Admission (median as nights; IQR) 5 (3)6 (1)0.010 Representation (within 30 days)890.789 Readmission (within 30 days)670.765 Total Length of Stay (median as nights; IQR) 5 (4)6 (3)0.009 OUTCOMES SO FAR LOS and Readmission 7

8. EXPOSURE [n=47] CONTROL [n=47] p-value Patients with Complications13120.815 Severity of Complications (Clavien-Dindo Grade) 0.362 I84 II711 III21 IV/V00 Nature of Complications Intraabdominal Infection (+/- Collection)680.562 Wound Infection101.000 Ileus/ Functional Bowel Obstruction420.677 Mechanical Bowel Obstruction101.000 Drug-Related130.753 Other431.000 Total Frequency of Complications 1716 OUTCOMES SO FAR Postoperative Complications 8

9. The Health Roundtable LESSONS LEARNT  Tailoring duration of postoperative antibiotic therapy for complicated appendicitis to a set of beside clinical parameters shortens LOS without apparent compromise to patient outcomes in children 9