ro13-9904 and Appendicitis

Development of secondary haemophagocytic lymphohistiocytosis (sHLH) in the context of typhoid fever (TF) is a very rare but serious complication.. Description of the first pediatric case of typhoid fever acquired in a non-endemic area complicated by sHLH. A systematic literature review of sHLH in the context of TF was performed with extraction of epidemiological, clinical and laboratory data.. The literature search revealed 17 articles (22 patients). Fifteen patients were eligible for data analysis (53.4% children). All patients had fever and pancytopenia. Transaminases and LDH were frequently elevated (46.6%). Salmonella typhi was detected mainly by blood culture (64.3%). All the patients received antibiotics whereas immunomodulation (dexamethasone) was used in two cases.. A high suspicion index for this condition is needed even in non-endemic areas. The addition of immunmodulation to standard antimicrobial therapy should be considered in selected cases.

Topics: Abdominal Abscess; Abdominal Pain; Age Distribution; Appendicitis; Asia; Ceftriaxone; Child; Developed Countries; Diagnosis, Differential; Endemic Diseases; Fever; Hepatomegaly; Humans; Lymphohistiocytosis, Hemophagocytic; Male; Methylprednisolone; Middle East; Sex Distribution; Spain; Splenomegaly; Typhoid Fever

Emerging data suggest instillation of tissue plasminogen activator (tPA) is safe and potentially efficacious in the treatment of intra-abdominal abscess. To date, prospective comparative data are lacking in children. Therefore, we conducted a randomized trial comparing abscess irrigation with tPA and irrigation with saline alone.. After IRB approval, children with an abscess secondary to perforated appendicitis who had a percutaneous drain placed for treatment were randomized to twice-daily instillation of 13 mL 10% tPA or 13 mL normal saline. All patients were treated with once-daily dosing of ceftriaxone and metronidazole throughout their course. The primary end point variable was duration of hospitalization after drain placement. Using a power of 0.8 and an α of 0.05, a sample size of 62 patients was calculated.. Sixty-two patients were enrolled between January 2009 and February 2013. There were no differences in demographics, abscess size, abscess number, admission WBC, or duration of symptoms. Duration of hospitalization after drainage was considerably longer with the use of tPA. There was no difference in total duration of hospitalization, days of drainage, or days of antibiotics. However, medication charges were higher with tPA.. There are no advantages to routine tPA flushes in the treatment of abdominal abscess secondary to perforated appendicitis in children.

Topics: Abdominal Abscess; Adolescent; Anti-Infective Agents; Appendicitis; Ceftriaxone; Child; Child, Preschool; Combined Modality Therapy; Drainage; Drug Administration Schedule; Drug Therapy, Combination; Female; Fibrinolytic Agents; Follow-Up Studies; Humans; Male; Metronidazole; Prospective Studies; Single-Blind Method; Sodium Chloride; Therapeutic Irrigation; Tissue Plasminogen Activator; Treatment Outcome

In 2009, we instituted a protocol to standardize care for patients undergoing interval appendectomy based on results from a prospective trial that demonstrated a reduction in the mean number of computed tomography (CT) scans performed. The goal of this study was to determine if our current practice now resulted in fewer CT scans as a result of this trial.. A retrospective review of all patients undergoing interval appendectomy for perforated appendicitis from March 2009 to March 2011 was performed. Demographics and outcomes were compared to previously collected data from a retrospective study prior to institution of the protocol and to the prospective trial.. During the study period, 45 patients underwent interval appendectomy. There were no differences in demographics among the three studies. Similar numbers of patients underwent aspiration or percutaneous drainage. There continues to be a significant reduction in the number of CT scans (3.5 ± 2.0 vs. 2.1 ± 1.3, P = 0.0001) and health care visits (7.6 ± 2.8 vs. 4.5 ± 1.4, P = 0.0001) when comparing management prior to the prospective trial to management since its completion.. A protocol for management of patients undergoing interval appendectomy care results in fewer health care visits and CT scans.

Topics: Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Child; Drainage; Female; Follow-Up Studies; Humans; Male; Metronidazole; Postoperative Care; Postoperative Complications; Prospective Studies; Retrospective Studies; Tomography, X-Ray Computed; Treatment Outcome

In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics.. Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days.. One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm.. When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.

Topics: Administration, Oral; Amoxicillin; Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Child; Dose-Response Relationship, Drug; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Injections, Intravenous; Laparoscopy; Male; Metronidazole; Preoperative Care; Prospective Studies; Rupture, Spontaneous; Treatment Outcome

This prospective, randomized, open, international, multicenter study of adults with complicated intra-abdominal infections (cIAI) compared the efficacy and safety of sequential intravenous (i.v.) to oral (p.o.) moxifloxacin 400 mg once daily, with that of i.v. ceftriaxone 2 g once daily, plus metronidazole 500 mg three times daily, followed by p.o. amoxicillin/clavulanate 625 mg three times daily. The primary efficacy variable was clinical cure at test of cure (TOC) (day 28-42 after study entry) in the per protocol (PP) population. Of 595 patients in the study, 511 patients were valid for PP analysis (246 moxifloxacin, 265 ceftriaxone/metronidazole). Sequential moxifloxacin was noninferior to the comparator regimen--clinical cure rates at TOC were 80.9% versus 82.3% (moxifloxacin versus ceftriaxone/metronidazole; 95% CI -8.9, 4.2%). The incidence of adverse events was comparable between the two treatment groups. Therefore, sequential moxifloxacin monotherapy is as effective and safe as combination therapy with i.v. ceftriaxone plus i.v. metronidazole followed by oral amoxicillin/clavulanate for the treatment of cIAI.

Topics: Abdominal Abscess; Administration, Oral; Adult; Aged; Amoxicillin-Potassium Clavulanate Combination; Anti-Infective Agents; Appendicitis; Aza Compounds; Bacterial Infections; Ceftriaxone; Drug Therapy, Combination; Female; Fluoroquinolones; Gastrointestinal Diseases; Humans; Infusions, Intravenous; Intestinal Perforation; Male; Metronidazole; Microbial Sensitivity Tests; Middle Aged; Moxifloxacin; Peritonitis; Prospective Studies; Quinolines

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.. After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82.. One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.. Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

Topics: Abscess; Administration, Oral; Adolescent; Antibiotic Prophylaxis; Appendectomy; Appendicitis; Ceftriaxone; Child; Cost-Benefit Analysis; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Therapy, Combination; Female; Follow-Up Studies; Gentamicins; Hospital Costs; Humans; Infusions, Intravenous; Male; Metronidazole; Multivariate Analysis; Probability; Prospective Studies; Treatment Outcome

To compare the therapeutic efficacy of four antibiotic regimens: penicillin, tobramycin, and clindamycin; penicillin, tobramycin, and ornidazole; piperacillin alone; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis.. Prospective randomised study.. Teaching hospital, Turkey.. 200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were randomly assigned to one of four groups each consisting of 50 patients.. Preoperative antibiotics given intravenously, peritoneal drainage by Penrose drains without irrigation, appendicectomy with the inversion of the stump by a purse string, taking peritoneal swabs, and primary skin closure.. Comparability of the groups, duration of fever, leucocytosis, antibiotic treatment, stay in hospital, nasogastric intubation, and drainage, as well as results of cultures and complications.. There were no significant differences between the groups for any variable studied. The predominant bacterial species were Escherichia coli, Klebsiella spp, Pseudomonas spp, Fusobacteria, and Peptostreptococci which were appropriately covered by all the antibiotic regimens. Fourteen patients had complications including wound infections (n = 10), prolonged ileus (n = 2) and intra-abdominal abscess (n = 2) all of which were treated conservatively. There was no mortality and no major complications. All regimens had the same clinical and bacteriological efficacy.. There is no gold standard for antimicrobial chemotherapy in perforated appendicitis. Different antibiotic combinations or a single broad spectrum antibiotic, which include both aerobic and anaerobic coverage, can safely be used in children with perforated appendicitis.

Topics: Adolescent; Amebicides; Anti-Bacterial Agents; Antibiotic Prophylaxis; Appendicitis; Ceftriaxone; Cephalosporins; Child; Child, Preschool; Clindamycin; Drug Therapy, Combination; Female; Humans; Injections, Intravenous; Intestinal Perforation; Male; Ornidazole; Penicillins; Piperacillin; Prospective Studies; Rupture, Spontaneous; Tobramycin; Treatment Outcome

Two hundred and forty adults undergoing acute appendicectomy were randomised to receive either cefoxitin or ceftriaxone 1 g intravenously at induction of anaesthesia. Patients were monitored daily while in hospital, and at least 4 weeks after discharge for evidence of wound, urinary or lower respiratory tract infection. We evaluated 167 patients at follow up and found no significant difference in infection rates between the two antibiotic groups. Thirty-four had normal appendices and 1 of 16 (6.3%) given cefoxitin and 2 of 18 (11.1%) given ceftriaxone developed wound infections. Ninety-seven had acute appendicitis and 3 of 48 (6.3%) given cefoxitin and 3 of 49 (6.1%) given ceftriaxone developed infections including 2 wound infections in each group. Thirty-six had gangrenous perforated or abscessed appendices: 31 were given additional antibiotics postoperatively, and 4 of 18 (22.2%) in each prophylactic antibiotic group developed infections, including wound infection in 3 given cefoxitin and in 4 given ceftriaxone. None of the infections were serious. Sixty-one percent presented after discharge from hospital. The mean hospital stay was 4.6 days for each antibiotic group. Neither antibiotic caused adverse effects.

Topics: Abscess; Adolescent; Adult; Appendectomy; Appendicitis; Cefoxitin; Ceftriaxone; Humans; Intestinal Perforation; Middle Aged; Premedication; Random Allocation; Rupture, Spontaneous; Surgical Wound Infection

Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database.. We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated.. We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant.. Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns.. Level III.. Retrospective Comparative Study.

Topics: Abdominal Abscess; Abscess; Adolescent; Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Child; Child, Preschool; Humans; Metronidazole; Piperacillin, Tazobactam Drug Combination; Postoperative Complications; Retrospective Studies; Treatment Outcome

Pathophysiology of appendicitis is associated with the underlying inflammatory processes. Ethyl pyruvate (EP) has potent antioxidant and anti inflammatory properties. In this study, we aimed to investigate the effects of EP on the treatment of appendicitis and to examine whether adding EP to the antibiotic treatment could increases the effectiveness of the treatment in a rat appendicitis model.. Thirty two Wistar rats, which had previously created appendicitis, were randomly divided into 4 groups: Group 1 (0.1 ml saline solution), Group 2 (15 mg/kg ceftriaxone), Group 3 (50 mg/kg EP), Group 4 (EP 50 mg/kg + ceftriaxone 15 mg/kg). In all groups, saline solution, ceftriaxone and EP were administered intraperitoneally and the same procedure was repeated twice a day for the following five days. On day 6, the rats underwent relaparotomy and then intraabdominal findings were recorded. Histopathological examination and interleukin 6 (IL 6) level were performed on appendiceal specimens.. Intra abdominal adhesion score was significantly lower in Group 4 than in Group 1. Total inflammation score was significantly lower in Group 2 than in Group 1 and was significantly lower in Group 4 than in Group 3 and 1. IL 6 level was significantly lower in Group 4 than in Group 3 and 1.. We found that adding EP to the antibiotic therapy increased the efficacy of the treatment in the rat appendicitis model. Further studies are required to apply our findings to the clinical setting.

Topics: Animals; Appendicitis; Ceftriaxone; Interleukin-6; Pyruvates; Rats; Rats, Wistar; Saline Solution

Narrow-spectrum antibiotics have been found to be equivalent to anti-Pseudomonal agents in preventing organ space infections (OSI) in children with uncomplicated appendicitis. Comparative effectiveness data for children with complicated appendicitis remains limited. This investigation aimed to compare outcomes between the most common narrow-spectrum regimen (ceftriaxone with metronidazole: CM) and anti-Pseudomonal regimen (piperacillin/tazobactam: PT) used perioperatively in children with complicated appendicitis.. Multicenter retrospective cohort study using clinical data from the NSQIP-Pediatric Appendectomy Collaborative database merged with antibiotic utilization data from the Pediatric Health Information System database. Mixed-effects multivariate regression was used to compare NSQIP-defined outcomes and resource utilization between treatment groups after adjusting for patient characteristics, disease severity, and clustering of outcomes within hospitals.. 654 patients from 14 hospitals were included, of which 37.9% received CM and 62.1% received PT. Following adjustment, patients in both groups had similar rates of OSI (CM: 13.3% vs. PT: 18.0%, OR 0.88 [95%CI 0.38, 2.03]), drainage procedures (CM: 8.9% vs. PT: 14.9%, OR 0.76 [95%CI 0.30, 1.92]), and postoperative imaging (CM: 19.8% vs. PT: 22.5%, OR 1.17 [95%CI 0.65, 2.12]). Treatment groups also had similar rates of 30-day cumulative post-operative length of stay (CM: 6.1 vs. PT: 6.0 days, RR 1.01 [95%CI 0.81, 1.25]) and hospital cost (CM: $19,235 vs. PT: $20,552, RR 0.92 [95%CI 0.69, 1.23]).. Rates of organ space infection and resource utilization were similar in children with complicated appendicitis treated with ceftriaxone plus metronidazole and piperacillin/tazobactam.. Level III: Treatment study - Retrospective comparative study.

Topics: Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Child; Humans; Metronidazole; Piperacillin, Tazobactam Drug Combination; Postoperative Complications; Retrospective Studies

Acute appendicitis is the most frequent surgical emergency in the paediatric population. Complicated appendicitis accounts for 30% of cases and is inextricably linked to postoperative infectious complications. A study at our institution showed that amoxicillin-clavulanate resistant Escherichia coli in complicated appendicitis was significantly linked to postoperative infectious complications. These findings led to a change in the empirical antibiotic protocol (amoxicillin-clavulanate changed to ceftriaxone + metronidazole as of 2017), intending to reduce postoperative infectious complications in complicated appendicitis in our institution.. This study aimed to analyse the microbiology and resistance profiles of pathogens of complicated appendicitis at our institution since implementing the new antibiotic protocol and the postoperative infectious complications rate.. We designed a retrospective comparative cohort study. During the defined study period (01 January 2017 to 31 July 2020), medical records were analysed for cases of acute appendicitis, complicated appendicitis and postoperative infectious complications, retaining only those who fulfilled inclusion criteria. Postoperative outcomes, microbiology and antibiotic resistance of peritoneal swabs were analysed.. During the study period, 95 patients presented with a complicated appendicitis, and 11 (12%) developed postoperative infectious complications. The most frequent pathogens found in complicated appendicitis were E. coli (66%), Streptococcus anginosus (45%), and Bacteroides fragilis (22%). Pseudomonas aeruginosa was present in 17% of complicated appendicitis. Pathogens involved in postoperative infectious complications mirrored the distribution found in complicated appendicitis without postoperative infectious complications. Antibiotic susceptibility analysis showed that 10 (15%) of E. coli strains were resistant to amoxicillin-clavulanate but sensitive to ceftriaxone + metronidazole, with only one strain responsible for causing a postoperative infectious complication. Six additional strains of E. coli (9%) were resistant to amoxicillin-clavulanate and our empirical antibiotic regimen but were not associated with an increase in postoperative infectious complications. Compared with our previous study, there was a decrease in postoperative infectious complications from 16% to 12%. Postoperative infectious complications caused by amoxicillin-clavulanate-resistant E. coli decreased from 28% to 9%.. This retrospective study demonstrated a decrease in the rate of postoperative infectious complications due to amoxicillin-clavulanate-resistant E. coli in complicated appendicitis. These findings accentuate the need to implement evidence-based treatment protocols based on local microbiology profiles and resistance rates to optimise post-operative antibiotics in complicated appendicitis.

Topics: Acute Disease; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Child; Clinical Protocols; Cohort Studies; Escherichia coli; Humans; Metronidazole; Postoperative Complications; Retrospective Studies

To compare rates of surgical site infection between the 2 most commonly utilized narrow-spectrum antibiotic regimens in children with uncomplicated appendicitis (ceftriaxone with metronidazole and cefoxitin alone).. Narrow-spectrum antibiotics have been found to be equivalent to extended-spectrum (antipseudomonal) agents in preventing surgical site infection (SSI) in children with uncomplicated appendicitis. The comparative effectiveness of different narrow-spectrum agents has not been reported.. This was a multicenter retrospective cohort study using clinical data from the Pediatric National Surgical Quality Improvement Program Appendectomy Collaborative Pilot database merged with antibiotic utilization data from the Pediatric Health Information System database from January 2013 to June 2015. Multivariable logistic regression was used to compare outcomes between antibiotic treatment groups after adjusting for patient characteristics, surrogate measures of disease severity, and clustering of outcomes within hospitals.. Eight hundred forty-six patients from 14 hospitals were included in the final study cohort with an overall SSI rate of 1.3%. A total of 56.0% of patients received ceftriaxone with metronidazole (hospital range: 0%-100%) and 44.0% received cefoxitin (range: 0%-100%). In the multivariable model, ceftriaxone with metronidazole was associated with a 90% reduction in the odds of a SSI compared to cefoxitin [0.2% vs 2.7%; odds ratio: 0.10 (95% confidence interval 0.02-0.60); P = 0.01].. Ceftriaxone combined with metronidazole is superior to cefoxitin alone in preventing SSIs in children with uncomplicated appendicitis.

Topics: Anti-Bacterial Agents; Appendectomy; Appendicitis; Cefoxitin; Ceftriaxone; Child; Drug Therapy, Combination; Female; Humans; Male; Metronidazole; Retrospective Studies; Surgical Wound Infection

Although perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis.. This is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared.. Forty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively.. Provider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.

Topics: Adolescent; Anti-Bacterial Agents; Antimicrobial Stewardship; Appendectomy; Appendicitis; Ceftriaxone; Child; Child, Preschool; Combined Modality Therapy; Decision Support Systems, Clinical; Drug Administration Schedule; Drug Therapy, Combination; Electronic Health Records; Female; Follow-Up Studies; Humans; Infant; Male; Metronidazole; Piperacillin, Tazobactam Drug Combination; Practice Patterns, Physicians'; Retrospective Studies; Treatment Outcome

Ceftriaxone is a wide-spectrum antibiotic frequently used in pediatrics. Biliary pseudolithiasis is a well-known side-effect occurring in 15-57% of cases. However, nephrolithiasis is extremely infrequent, with very few related publications.. We present the case of a 9-year-old patient with ceftriaxone-treated complicated acute appendicitis who developed biliary pseudolithiasis and nephrolithiasis. During hospitalization, the patient presented with pseudolithiasis complications such as mild pancreatitis and bilateral ureterohydronephrosis with acute renal failure.. Suspecting ceftriaxone-associated biliary pseudolithiasis and/or nephrolithiasis is key to achieve an early diagnosis and prevent complications such as those reported in this patient. Early discontinuation is essential as an initial treatment measure.. La ceftriaxona es un antibiótico de amplio espectro frecuentemente utilizado en pediatría. La pseudolitiasis vesicular es un efecto adverso bien conocido, que se presenta en un 15 a 57% de los casos. En cambio la litiasis renal es extremadamente infrecuente con muy pocas publicaciones al respecto.. Se presenta el caso de un paciente de 9 años que, durante tratamiento con ceftriaxona por una apendicitis aguda complicada, desarrolla pseudolitiasis vesicular y urinaria. Durante la misma internación el paciente presenta una pancreatitis leve y una ureterohidronefrosis bilateral, con insuficiencia renal aguda, como complicaciones de las pseudolitiasis.. La sospecha de la formación de litiasis renal y/o vesicular asociada al uso de ceftriaxona es fundamental para un diagnóstico temprano y prevención de complicaciones como las reportadas en este paciente, siendo fundamental la suspensión precoz del fármaco como inicio del tratamiento.

Topics: Acute Kidney Injury; Anti-Bacterial Agents; Appendicitis; Ceftriaxone; Child; Humans; Kidney Calculi; Male; Pancreatitis

To assess compliance of antibiotic prophylaxis in surgery for acute appendicitis in children and its effect on surgical site infection.. We carried out a prospective cohort study to evaluate compliance of antibiotic prophylaxis in appendectomies in children. An assessment of the level of compliance with prophylaxis was made, as well as the causes of non-compliance. The effect of non-compliance of antibiotic prophylaxis on the incidence of surgical site infection was studied with the adjusted relative risk (RR) with a backstep logistic regression model.. The study included a total of 412 patients. Antibiotic prophylaxis was indicated in 348 patients, and administered in 95.7% of cases, with an overall protocol compliance of 90.7%. The principal cause of non-compliance was time of initiation. Cumulative incidence of surgical site infection was 2.7%. No relationship was found between inadequate prophylaxis compliance and infection (RR: 1.01; 95% confidence interval: 0.95-1.11; p = 0.61).. Compliance of antibiotic prophylaxis was high, but could be improved. No relationship was found between prophylaxis compliance and surgical site infection rate.. Evaluar la adecuación de la profilaxis antibiótica en la cirugía de apendicitis aguda en niños y su efecto en la infección del sitio quirúrgico.. Estudio de cohortes prospectivo para evaluar la adecuación al protocolo de la profilaxis antibiótica en apendicectomías en población infantil. Se evaluaron la administración de la profilaxis y las causas de la inadecuación. Se estudió el efecto de la inadecuación en la incidencia de infección del sitio quirúrgico con el riesgo relativo (RR) ajustado con un modelo de regresión logística por pasos hacia atrás.. Se estudiaron 412 pacientes. La profilaxis antibiótica estaba indicada en 348 pacientes y se administró en el 95.7% de los casos, con una adecuación global al protocolo del 90.7%. La causa principal del incumplimiento fue la hora de inicio. La incidencia acumulada de infección del sitio quirúrgico fue del 2.7%. No se encontró relación entre la adecuación de la profilaxis y la infección del sitio quirúrgico (RR: 1.01; intervalo de confianza del 95%: 0.95-1.11; p = 0.61).. La adecuación de la profilaxis antibiótica fue alta, pero puede mejorarse. No se encontró relación entre la adecuación de la profilaxis antibiótica y la incidencia de infección del sitio quirúrgico.

Topics: Acute Disease; Amoxicillin-Potassium Clavulanate Combination; Ampicillin; Antibiotic Prophylaxis; Appendectomy; Appendicitis; Cefazolin; Ceftriaxone; Child; Child, Preschool; Confidence Intervals; Drug Administration Schedule; Female; Gentamicins; Guideline Adherence; Humans; Incidence; Logistic Models; Male; Medication Adherence; Metronidazole; Prospective Studies; Surgical Wound Infection

The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis.. There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis.. Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates.. Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)].. Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.

Topics: Adolescent; Anti-Bacterial Agents; Appendectomy; Appendicitis; Cefoxitin; Ceftriaxone; Child; Child, Preschool; Comparative Effectiveness Research; Drug Therapy, Combination; Female; Humans; Male; Metronidazole; Patient Readmission; Piperacillin, Tazobactam Drug Combination; Propensity Score; Retrospective Studies; Surgical Wound Infection; Treatment Outcome

 Acute appendicitis is the most common emergency condition in pediatric surgery. Historically, a triple-antibiotic therapy consisted of ampicillin, gentamicin, and clindamycin has been used postoperatively for perforated appendicitis. According to recently published trials, dual therapy consists of ceftriaxone and metronidazole only, offers a more efficient and cost-effective antibiotic management compared with triple therapy. Based on these results, our department applied dual antibiotic therapy for children with perforated appendicitis that underwent appendectomy from 2009 and forth..  The aim of our study was to compare postoperative outcomes between patients treated with triple therapy (ampicillin, gentamicin, and metronidazole) (group A) versus dual therapy (ceftriaxone and metronidazole) (group B)..  Clinical and laboratory data were retrospectively collected by review of the medical records for all children who underwent appendectomy for the perforated appendix at the Schneider Children's Medical Center of Israel, a tertiary pediatric care center between 2007 and 2011. Children with perforated appendicitis received antibiotic therapy in accordance with the hospital's guidelines that were valid at the time the surgery took place. In the first period (years 2007-2009) (group A) a triad of ampicillin, gentamicin, and metronidazole and the second period (2009-2011) (group B) dual therapy consists of ceftriaxone and metronidazole. The two groups were compared for outcome and complications, such as wound infections, changing of antibiotic therapy, and length of stay..  Dual antibiotic therapy for perforated appendicitis is a cost-effective and efficient mode of therapy compared with triple-antibiotic's regimen. However, prospective studies are required to determine whether this policy is associated with higher rates of wound infections and change in antibiotic therapy.

Topics: Acute Disease; Ampicillin; Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Chemotherapy, Adjuvant; Child; Clindamycin; Drug Therapy, Combination; Female; Gentamicins; Humans; Male; Metronidazole; Retrospective Studies; Treatment Outcome

Appendicitis is a common surgical emergency in pediatric patients, and broad-spectrum antibiotic therapy is warranted in their care. A simplified once-daily regimen of ceftriaxone and metronidazole (CTX plus MTZ) is cost effective in perforated patients. The goal of this evaluation is to compare a historic regimen of cefoxitin (CFX) in nonperforated cases and ertapenem (ERT) in perforated and abscessed cases with CTX plus MTZ for all cases in terms of efficacy and cost.. A retrospective review compared outcomes of nonperforated, perforated, and abscessed cases who received the historic regimen or CTX plus MTZ. Length of stay, time to afebrile, time to full feeds, postoperative abscess, and wound infection rates, inpatient readmissions, and antibiotic costs were evaluated.. There were a total of 841 cases reviewed (494 nonperforated, 247 perforated, and 100 abscessed). Overall, the CTX plus MTZ group had a shorter time to afebrile (P < .001). Treatment groups did not differ in length of stay. Postoperative abscess rates were similar between groups (4.1% vs 3.3%, not significant). Other postoperative complications were similar between groups. Total antibiotic cost savings were over $110 000 during the study period (from November 2010 to June 2013).. Both CFX and/or ERT and CTX plus MTZ result in low abscess and complication rates, suggesting both are effective strategies. Treatment with CTX plus MTZ results in a shorter time to afebrile, while also providing significant antibiotic cost savings. Ceftriaxone plus MTZ is a streamlined, cost-effective regimen in the treatment of nonperforated, perforated, and abscessed appendicitis.

Topics: Abdominal Abscess; Adolescent; Appendectomy; Appendicitis; beta-Lactams; Cefoxitin; Ceftriaxone; Child; Child, Preschool; Cost Savings; Cost-Benefit Analysis; Drug Administration Schedule; Drug Substitution; Drug Therapy, Combination; Ertapenem; Female; Humans; Infant; Laparoscopy; Male; Metronidazole; Retrospective Studies; Treatment Outcome; Young Adult

In a previous randomized trial, we found children with perforated appendicitis could be safely discharged prior to completion of a 5 day intravenous antibiotics course. To progress the protocol further, patients who met discharge criteria early were discharged without oral antibiotics if leukocyte counts were normal.. Children undergoing laparoscopic appendectomy for perforated appendicitis were prospectively observed after institution of a new antibiotic regimen consisting of daily intravenous dosing ceftriaxone/metronidazole while an inpatient. Patients discharged prior to 5 days were discharged home without oral amoxicillin-clavulanate if no leukocytosis at discharge. Outcomes were compared to the previous protocol of daily intravenous ceftriaxone/metronidazole with completion of a 7-day antibiotic course with amoxicillin-clavulanate of all patients discharged prior to 5 days.. 540 patients (270 new protocol, 270 old protocol) were identified. There was no significant difference in patient demographics, admission leukocyte count, time to regular diet, or length of stay. Postoperative abscess occurred in 21.8% in the new protocol compared to 19.3% of the previous (P=0.5). There was a significant decrease in the number of patients discharged home on oral antibiotic therapy (P<0.001).. Patients meeting discharge criteria with normal leukocyte count prior to completion of 5 days IV antibiotic therapy can be safely discharged home without oral antibiotics after laparoscopic appendectomy for perforated appendicitis.

Topics: Administration, Oral; Adolescent; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Child; Child, Preschool; Clinical Protocols; Combined Modality Therapy; Drug Administration Schedule; Drug Therapy, Combination; Female; Humans; Injections, Intravenous; Laparoscopy; Male; Metronidazole; Patient Discharge; Postoperative Care; Prospective Studies; Treatment Outcome

Ceftriaxone has been associated with development of pseudolithiasis. In our institution, it is used for treatment of perforated appendicitis in children. This study evaluated the occurrence of ceftriaxone-related pseudolithiasis in this population.. After obtaining IRB approval, we performed a retrospective chart review over 51 months. We included patients undergoing laparoscopic appendectomy for perforated appendicitis. All patients were treated with ceftriaxone post-operatively. Patients without initial or post-treatment gallbladder imaging available for review were excluded.. There were 71 patients who met inclusion criteria with a mean (±SD) age of 10.8 ± 3.8 years. Of these, 14 % (n = 10) developed stones or sludge in the gallbladder. The mean duration of ceftriaxone therapy was 8.7 ± 3.8 days. The average time to post-antibiotic imaging was 11.5 ± 10.3 days from initiation of antibiotics. There was no significant difference in duration of ceftriaxone therapy in the children that developed pseudolithiasis or sludge (10.0 ± 4.9 days) compared to those that did not (8.5 ± 3.6, p = 0.26). One child (10 %) with pseudolithiasis went on to become symptomatic, requiring a laparoscopic cholecystectomy.. In our experience, ceftriaxone use for perforated appendicitis is associated with a significant incidence of biliary pseudolithiasis, and is unrelated to duration of ceftriaxone therapy.

Topics: Anti-Bacterial Agents; Appendicitis; Ceftriaxone; Child; Cholelithiasis; Female; Follow-Up Studies; Humans; Male; Retrospective Studies; Time Factors

This study aimed to assess the long-term (>12 months) efficacy of nonoperative treatment (antibiotic administration) in the management of uncomplicated acute appendicitis (AA).. We surveyed uncomplicated AA patients who elected to undergo nonoperative treatment between 2010 and 2012. A binary logistic regression analysis was performed to identify the critical predictors of recurrence. Age, gender, presence of appendicolith, and white blood cell count on admission were analyzed as possible predictors of recurrence.. The median follow-up period of the study was 23 months. Twelve of 118 patients (10.2%) were diagnosed with recurrent appendicitis. Seven were retreated with the same antibiotic protocol and did not show further recurrence. The binary logistic regression analysis revealed statistical significance only for the presence of appendicolith [P=0.001, Exp (B)=0.058, B=-2.845]. Recurrence rate was lower in the presence of appendicolith.. Nonoperative treatment of uncomplicated AA is an effective option. Recurrence is rare and it can be addressed efficiently with the administration of a second course of antibiotics. The presence of appendicolith should not discourage physicians from prescribing nonoperative treatment for patients with uncomplicated AA.

Topics: Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Ampicillin; Anti-Bacterial Agents; Appendicitis; Ceftriaxone; Chemotherapy, Adjuvant; Female; Follow-Up Studies; Humans; Lithiasis; Male; Metronidazole; Middle Aged; Recurrence; Risk Factors; Sulbactam; Time Factors; Young Adult

Topics: Abdominal Pain; Anti-Bacterial Agents; Appendicitis; Ceftriaxone; Colonoscopy; Humans; Male; Middle Aged

Complicated appendicitis has significant infective postoperative morbidity. There is no universally-accepted antibiotic regime, although traditionally, triple antibiotics are recommended. Our complicated appendicitis clinical pathway recommends ceftriaxone and metronidazole. The study aimed to determine if choice of antibiotics influenced the risk of infective complications.. We reviewed all paediatric appendicectomy patients between January 1, 2005 and December 31, 2005. All patients with intraoperative diagnosis of perforated appendicitis were recruited, excluding infants, immunocompromised patients, and patients allergic to the guideline antibiotics. All operations were performed by registrar/consultant surgeons and were laparoscopic, unless technically not feasible.. There were 82 patients with perforated appendicitis. 62 patients (76 percent) followed pathway antibiotics, and 20 patients (24 percent) deviated from the pathway by receiving additional empiric gentamycin. We compared the pathway compliant and deviation groups, and found no significant differences in patient characteristics, clinical presentation, operation, length of stay and infective complications. Overall there was one wound infection and five (six percent) postoperative abscesses. Initial peritoneal cultures and subsequent drainage cultures of patients who developed abscesses were sensitive to treatment antibiotics.. In complicated appendicitis, empirical perioperative addition of gentamycin to ceftriaxone and metronidazole did not reduce the risk of developing intra-abdominal abscess, compared to changing antibiotics on clinical grounds. Patients developed postoperative abscesses despite initial peritoneal cultures growing organisms sensitive to treatment antibiotics.

Topics: Abdominal Abscess; Anti-Bacterial Agents; Appendectomy; Appendicitis; Ceftriaxone; Child; Female; Humans; Male; Metronidazole; Postoperative Complications; Postoperative Period; Surgical Wound Infection

Topics: Abdominal Abscess; Appendicitis; Cefoxitin; Ceftriaxone; Cefuroxime; Child; Community-Acquired Infections; Drug Resistance, Microbial; Enterobacteriaceae; Enterobacteriaceae Infections; Humans; Metronidazole; Pseudomonas; Pseudomonas Infections; Randomized Controlled Trials as Topic

Abdominal pain is common feature of Henoch-Schonlein purpura, which may mimic appendicitis, leading to unnecessary laparotomy. Accordingly, the diagnosis must be confirmed by ultrasonography or computed tomography scan before laparotomy is performed. The authors report a case of simultaneous occurrence of Henoch-Schonlein Purpura and gangrenous appendicitis in an 18 year-old boy. The patient was admitted with abdominal pain, cramps, and mild dehydration. He also complained of small reddish purple on his lower limbs, bilateral knee pain, low-grade fever, as well as bloody stools. The symptoms subsided completely. Eight days later, he returned with nonbloody, nonbilious emesis, abdominal cramps, and right lower quadrant abdominal tenderness. Abdominal ultrasound evaluation was performed to rule out an intussusception but demonstrated appendiceal dilatation with a possible appendicolith without any evidence of intussusception. A laparotomy was undertaken, and appendectomy was performed for gangrenous appendicitis. Simultaneous occurrence of Henoch-Schonlein purpura and acute appendicitis is rarely observed. Clinical features of the patients may mislead the clinicians, resulting in delayed diagnosis or misdiagnosis. The use of ultrasonography and computed tomography scan would confirm the diagnosis before surgery.

Topics: Abdominal Pain; Adolescent; Anti-Bacterial Agents; Appendectomy; Appendicitis; Arthralgia; Ceftriaxone; Combined Modality Therapy; Diagnosis, Differential; False Negative Reactions; Fever; Gangrene; Gastrointestinal Hemorrhage; Humans; Hydrocortisone; IgA Vasculitis; Intussusception; Male; Metronidazole; Prednisone; Ultrasonography

Appendicitis is the most common abdominal emergency in children. When perforation is encountered, postoperative management is grounded upon the use of intravenous antibiotics. The 3-drug regimen of ampicillin, gentamicin, and clindamycin has long been the accepted standard by pediatric surgeons. Although effective and seemingly inexpensive, this regimen produces a cumbersome dosing schedule, which has inspired the search for a simpler regimen that does not compromise efficacy or expense. To this end, we have introduced a 2-drug regimen of ceftriaxone and Flagyl (Pharmacia Corporation, Chicago, Ill) with once-a-day dosing.. A retrospective review was conducted of the most recent 250 patients treated at our institution with perforated appendicitis. Patients treated since the implementation of this 2-drug regimen were compared with the recent historical cohort treated with triple antibiotic coverage. Parameters analyzed between the 2 groups included temperature curves for the first 5 postoperative days, abscess rate, length of hospitalization, length of intravenous antibiotic treatment, and medication charges.. The 2-drug regimen was used in 57 patients (group 1) compared with 193 patients treated with triple antibiotic coverage (group 2). Maximum recorded temperature between the 2 groups was similar upon admission, but the mean maximum temperature in group 1 became significantly lower than group 2 from postoperative day 1 onward (P < .001). Postoperatively, an abscess developed in 8.8% of group 1 compared with 14.2% of group 2, which was not significantly different (P = .37). Mean length of stay was 6.8 days in group 1 and 7.8 days in group 2 (P = .03). Medication charges to the patient were 81.32 dollars per day in group 1 compared with 318.53 dollars per day in group 2, translating to 1186.05 dollars savings for 5 days.. Once-a-day dosing with ceftriaxone and Flagyl provides adequate antibiotic coverage for the postoperative management of perforated appendicitis in children. This regimen allows patients to more rapidly defervesce compared with traditional triple antibiotic coverage; moreover, this simple regimen provides substantial advantages for administration and expense.

Topics: Adolescent; Anti-Bacterial Agents; Antibiotic Prophylaxis; Appendicitis; Ceftriaxone; Child; Child, Preschool; Cost-Benefit Analysis; Female; Humans; Male; Metronidazole; Retrospective Studies