1. Shiva Sharma, Breast/Endocrine S.H.O

2.  Most common presentation requiring surgery  Great variability with regards to:  Timing  Choice  Route of administration  Instances of use

3.  Perforated vs. Non-Perforated appendicitis  Pre-operative antibiotics  Needed?  Benefit vs. Cost  Timing  How long?

4.  The use of antibiotics in perforated well est.  Risk of intra-abdominal contamination  Risk of abscess formation  Triple therapy previously  Gram positive, Gram negative and aerobic coverage  Broad-spectrum single or double agent therapy as effective

5.  Morbidity  Wound infection  Intra-abdominal abscess  Timing of surgery  Presenting with NPA progressing to perforation  Time of presentation to time of surgery  Sepsis increases as appendicitis progresses

6.  Cost of antibiotics  Monetary  Risk of reaction  Antibiotic related secondary infection  Resistance  Cost of out of hours operating  Hospital beds

7.  Optimum duration of prophylactic antibiotics in non-perforated appendicitis  Following underwent emergency open appendicectomies  Group A: single dose antibiotic pre-operative  Group B: Three dose/1 Day  Group C: 5 day peri-operative course

8.  Results: no significant impact on length of hospital stay  Wound infection rates ▪ 6.5%, 6.4%, 3.6%  Increase in antibiotic related complications in the 5day group ▪ 0%, 1.1%, 4.8% ▪ L.M. Mui etal. ANZ Journal of Surgery. 2005; 75:425

9.  Timing of intervention does not affect outcome in acute appendicitis  Retrospective study  1198 patients  Mean time to surgery 7.1hr, range 1-24hr  Concluded: short delays from time to surgery well tolerated

10.  No relation between timing to surgical intervention and length of hospital stay  Complications more related to NPA vs. Perforated  Paper does not specify if antibiotics are used  Suggests that surgery can be delayed provided infection can be controlled ▪ C.Clyde etal; Am. Journal of Surgery (2008) 195; 590

11.  Antibiotics and appendicitis in the pediatric population – Systematic Review  Presented at the 2010 Meeting of the American Pediatric Surgical Association  Review of PubMed and other English Literature up to 2009

12.  Grade A evidence to support children should receive preoperative antibiotics  Cochrane review supports single dose preoperative antibiotics  Significant decrease in wound infection and intra-abdominal abscess

13.  Grade B evidence to support single or double agent antibiotics in perforated cases  More effective, cost effective and similar rates as triple therapy  Total course of antibiotics should be 7 days  Minimum 5 days IV

14.  Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee Systematic Review; S.L. Lee etal. Journal of Pediatric Surgery (2010) 45, 2181  Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendectomy Cochrane Database Syst Rev 2005;3  Donovan, I. A., D. Ellis, D. Gatehouse, G. Little, R. Grimley, S.Armstead, M. R. B. Keighley, and C. J. C. Strachan. 1979. One dose antibiotic prophylaxis against wound infection after appendectomy. A randomized trial of clindamycin, cefazolin sodium and a placebo. Br. J. Surg. 66:193-196.  Timing of intervention does not affect outcome in acute appendicitis. L.M. Mui etal. ANZ Journal of Surgery. 2005; 75:4  Timing of intervention does not affect outcome in acute appendicitis in a large community practice; The American Journal of Surgery (2008) 195, 590–593