AAP Papers
A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial

https://doi.org/10.1016/j.jpedsurg.2010.02.090Get rights and content

Abstract

Introduction

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.

Methods

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.

Results

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.

Conclusions

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.

Section snippets

Methods

Approval was obtained from the Children's Mercy Hospital Internal Review Board (IRB) (IRB# 07 02-031) before enrolling patients in this study. Patients were subsequently enrolled only after obtaining consent from the patient's legal guardian. The consent forms and consent process were carefully evaluated by the IRB on a continual basis. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT# 00462020).

Results

From March 2007 through October 2008, 102 patients were enrolled in the study. Accrual of patients was terminated after the interim analysis when the primary outcome variable (postoperative abscess rate) was found to be identical between the 2 groups.

Discussion

Despite the large volume of children with perforated appendicitis, there is a paucity of prospective data on which management strategies can be based. As a result, wide variability exists in the postoperative management of these patients. A survey of APSA members in 2003 showed that 63.4% use 4 to 7 days of IV antibiotics, while only 3.2% use 1 to 3 days of IV antibiotics [2]. This still leaves a significant portion of pediatric surgeons who routinely employ at least 8 days of IV antibiotics. A

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