Insufficient antibiotic regimen leads to more complications in paediatric appendectomy

In paediatric patients undergoing appendectomy, an insufficient antibiotic regimen may result in longer length of stay (LOS) and more infectious complications, which validates the expansion of a simple antibiotic regimen in cases of severe intra-abdominal findings, a study has shown. In uncomplicated cases of appendicitis, treatment with ampicillin-sulbactam (AS) is suggested.

“This therapy has several advantages compared with a cefuroxime-metronidazole (C-M) regimen, such as its high activity against enterococci and its favourable role in relation to development of further bacterial resistances,” the researchers said.

A total of 1,258 paediatric patients who underwent appendectomy from 2012 to 2020 were included in this retrospective, monocentric study on antibiotic susceptibility. The researchers determined predictors for prolonged LOS and complications using regression analysis and identified objective criteria for broad-spectrum antibiotic regimens.

In addition, they carried out simulations of the effectiveness of different antibiotic regimens against identified bacterial susceptibility results.

Insufficient primary antibiotic treatment, as well as elevated preoperative C-reactive protein levels and high intraoperative severity gradings, were significantly associated with prolonged LOS and a higher rate of infectious complications. [Pediatr Infect Dis J 2022;41:460-465]

A simple antibiotic regimen, consisting of C-M or AS, was adequate in about 85 percent of patients, with either option showing efficiency. In severe appendicitis, the odds of resistance were 31 percent with C-M and 32 percent with AS.

Furthermore, the incidence of bacterial resistance decreased to 12 percent for piperacillin-tazobactam and C-M-tobramycin. Resistance dropped to 8 percent for AS-tobramycin therapy. Of note, patients with a high intraoperative severity grading benefitted most from an extended antibiotic regimen.

“The data from our large, yet retrospective study, and from a smaller, but randomized trial study by Foster et al, advocates the use of an aminopenicillin in combination with a beta lactamase inhibitor (eg, AS) in all children with uncomplicated appendicitis, except in cases of intolerance or known resistance,” the researchers said. [J Pediatr Surg 1987;22:869-872; Rev Infect Dis 1986;8 suppl 5:S634-S638]

“Besides being highly effective, aminopenicillins are generally tolerated better than cephalosporins, are cost-effective, and can be [easily given in oral form],” they added.

Moreover, adverse reactions reported with the use of aminopenicillins were only minor. [Drugs 2007;67:1829-1849; Drugs 1987;33:577-609; Drugs 1996;52:125-158]

Cefuroxime, on the other hand, offered some disadvantages. While effective as an antibiotic agent against a wide range of Gram-negative bacteria, cephalosporins are not effective against enterococci, which are usually grown in swabs obtained from patients with acute appendicitis. [Infect Dis Clin North Am 1989;3:571-594; Arch Surg 2006;141:1162-1167]

Cephalosporins are generally well tolerated, but they can induce severe hypersensitivity reactions and represent a leading cause for perioperative anaphylaxis. [J Allergy Clin Immunol Pract 2019;7:2105-2114]

“Currently, a range of different antibiotics are administered perioperatively during appendectomy surgery in the paediatric population,” the researchers said. “One reason for the lack of a uniform treatment regimen is the paucity of large studies on microbiologic data and susceptibility patterns.”