Journal of Pediatric Surgery 50 (2015) 912–914
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Safety of a new protocol decreasing antibiotic utilization after laparoscopic appendectomy for perforated appendicitis in children: A prospective observational study Amita A. Desai, Hanna Alemayehu, George W. Holcomb III, Shawn D. St. Peter ⁎ Department of Surgery, Children's Mercy Hospital, Kansas City, MO
a r t i c l e
i n f o
Article history: Received 28 February 2015 Accepted 10 March 2015 Key words: Appendicitis Antibiotic Children Perforated
a b s t r a c t Introduction: 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. Methods: 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. Results: 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 b 0.001). Conclusions: 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. © 2015 Elsevier Inc. All rights reserved.
Practice patterns in the surgical and medical management of perforated appendicitis after antibiotics are widely variable [1,2]. At our institution, we commonly operate within 24 hours of presentation and length of intravenous antibiotic therapy has been evolving the past 8 years with the initiation of our first randomized trial that demonstrated once-daily dosing of ceftriaxone and metronidazole provides adequate antimicrobial therapy compared with previous traditional triple antibiotic therapy [3]. All of the patients received a minimum 5 days of intravenous (IV) antibiotic therapy. A second randomized trial of 100 patients was conducted comparing a minimum 5 day course of IV ceftriaxone and metronidazole to the opportunity to convert to oral (PO) antibiotics if clinically well prior to day 5 to complete a total of 7 days of combined therapy. This study found the conversion or oral antibiotics when able did not have an effect on risk of postoperative abscess [4]. We subsequently performed a third trial in 220 patients comparing irrigation to no irrigation during appendectomy in which all patients were managed with the management scheme of sending patients home with oral antibiotic when able [5]. This study found no ⁎ Corresponding author at: Department of Surgery, Children's Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO USA 64108. Tel.: +1 816 983 6465; fax: +1 816 983 6885. E-mail address: [email protected] (S.D. St. Peter). http://dx.doi.org/10.1016/j.jpedsurg.2015.03.006 0022-3468/© 2015 Elsevier Inc. All rights reserved.
differences in any outcomes. At this point we had 270 patients prospectively enrolled who were treated with the protocol of early conversion to PO antibiotics if clinically well prior to day 5 to complete 7 days combined therapy. In order to progress the protocol further, we conducted a prospective observational study in the next 270 patients admitted in which patients could be discharged home early without PO antibiotics if a leukocytosis is not identified at time of discharge prior to completion of a 5 day IV antibiotic course.
1. Methods After IRB approval (IRB #11120174), all children (Group 1) who underwent laparoscopic appendectomy for perforated appendicitis were prospectively observed from August 2011 to January 2014 with the institution of the new attenuated antibiotic regimen. These patients were compared to the patients enrolled in the 2 previous trials (Group 2) who received IV antibiotic therapy with PO antibiotics if discharged prior to day 5 [4,5]. Perforation was defined as hole in the appendix or fecalith in the abdomen as previously described [6]. Discharge criteria were met when patients were tolerating regular diet with pain controlled on oral pain medications and no fever
A.A. Desai et al. / Journal of Pediatric Surgery 50 (2015) 912–914
913
Fig. 1. Protocol used for 270 patients over 2 trials.
recorded over the previous 12 hours. Patients who met these criteria had a complete blood count drawn to evaluate for leukocytosis. Patients under the new study protocol (Group 1) received 50 mg/kg (max 2 g) IV ceftriaxone and 30 mg/kg (max 1 g) IV metronidazole every 24 hours. Patients who completed minimum 5 days of IV antibiotics were discharged home without oral antibiotics. Patients who met discharge criteria prior to 5 days, were discharged home with oral amoxicillinclavulanate for completion of 7-day antibiotic course if they had a leukocytosis on day of discharge. If leukocyte count was normal, regardless of differential counts, they were discharged without oral antibiotics. Patients under the old protocol in the comparison group (Group 2) also received daily dosing of IV ceftriaxone and metronidazole. All patients who met discharge criteria prior to completion of 5 days of IV antibiotics were discharged home with amoxicillin-clavulanate to complete 7 day course of antibiotics (Fig. 1) [4,5]. All patients in both groups received preoperative doses of ceftriaxone and metronidazole The outcome parameter compared between the two groups was abscess formation. Statistical evaluation performed between the two groups consisted of unpaired 2-tailed Student's t-test for continuous variables. Fisher exact and Chi-square with Yates correction were used for discrete variables where appropriate. 2. Results The new protocol reducing length of antibiotic therapy based on leukocyte count (Group 1) was used in 270 patients compared with 270 Table 1 Demographics of patients in receiving the new postoperative antibiotic protocol (Group 1) and previous protocol (Group 2) after laparoscopic appendectomy for perforated appendicitis.
Gender (M) Mean age (y) BMI Admission WBC Mean maximum temperature on admission
Group 1 (n = 270)
Group 2 (n = 270)
P
60 9.6 ± 3.8 19.2 ± 5.2 17.6 ± 5.7 37.7 ± 0.9
150 10 ± 3.9 19.8 ± 4.9 17.4 ± 5.8 37.9 ± 0.9
0.6 0.2 0.2 0.7 0.2
patients of previous protocol utilizing oral antibiotics to complete 7 day course if discharged early. There was no significant difference in patient demographics including gender, mean age, weight, height, or BMI as can be seen in Table 1. There was also no significant difference in objective measures at presentation including admission white blood cell (WBC) count or maximum temperature. No difference existed in operative time, time to regular diet intake, postoperative length of stay, or rate of abscess formation between the two groups. There was no difference in identification of postoperative abscess as inpatient and after discharge between the two groups. There was however a significant difference in number of patients discharged home on oral antibiotics without abscess identification prior to discharge. Of those patients who were not discharged home on oral antibiotics, there was no significant difference in rate of identification of postoperative abscess (Table 2). 152 patients in Group 1 were discharged before postoperative day 5. Of these 152 patients in the new protocol, 17 had an elevated leukocyte count and thus discharged home with PO antibiotics to complete 7 day course leaving 135 patients being discharged without antibiotics. 12 of these 152 patients (7.9%) were subsequently found to have an intraabdominal abscess. Of the 135 patients discharged home without PO antibiotics, 11(8.1%) were found to have a postoperative abscess after discharge. Only 1 (5.8%) of the 17 patients discharged home early with PO antibiotics was found to have a postoperative abscess. In Group 2, 136 patients were discharged before day 5 and all were given oral antibiotics. Of these patients 6 (3.9%) were subsequently found to have an abscess. Although this is not significant (P = 0.1), this difference could be more meaningful in a larger population (Table 3). Table 2 Outcomes of patients in receiving the new postoperative antibiotic regimen (Group 1) and previous postoperative antibiotic regimen (Group 2) after laparoscopic appendectomy for perforated appendicitis.
Operative time (min) Mean time to regular diet (hr) Mean postoperative length of stay Postoperative abscess Abscess diagnosed before discharge Abscess diagnosed after discharge
Group 1
Group 2
P-value
41.0 ± 18.6 83.2 ± 48.7 5.4 ± 2.9 59 (21.8%) 40 19 (7%)
41.6 ± 16.5 80.3 ± 37.9 5.4 ± 3.5 52 (19.3%) 34 18 (6.7%)
0.7 0.4 1.0 0.5 0.5 0.9
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A.A. Desai et al. / Journal of Pediatric Surgery 50 (2015) 912–914
Table 3 Patients discharged home prior to completion of 5 days IV antibiotic therapy.
Discharge home on PO antibiotics Postoperative abscess Postoperative abscess, on home PO antibiotics Postoperative abscess, without home PO antibiotics
New protocol group 1 (n = 152)
Old protocol group 2 (n = 136)
P-value
17 12/152 (7.9%) 1/17 (5.8%) 11/135 (8.1%)
136 6/136 (4.4%) 6/136 (4.4%) n/a
n/a 0.3 0.6 n/a
Patients who were discharged home prior to 5 days without PO antibiotics had a leukocyte count of 8.6 ± 2.4, and those discharged with PO antibiotics had a leukocytosis of 16.9 ± 3.5 (P b 0.001). When comparing these two groups, there was no significant difference in patient demographics.
3. Discussion Antibiotic therapy for treatment of perforated appendicitis has evolved over the past several decades. Traditionally, children were treated with up to 2 weeks of triple IV antibiotic therapy in attempt to prevent intraabdominal abscess formation [7,8]. This was followed by earlier discharge of patients home on IV antibiotics with use of PICC line with demonstration of similar efficacy with significant cost savings [9,10]. Since that time, it has been demonstrated in several studies that patients can be safely discharged home earlier on PO antibiotics when discharge criteria have been met [11–13]. In order to prevent interprovider variability, an evidence based definition of perforation as a hole in appendix or fecalith in abdomen used in previous prospective randomized trials was applied to the prospectively observed cohort after institution of the new protocol [6]. The overall incidence of postoperative abscess formation, after laparoscopic appendectomy did not significantly change under the new protocol. In a recently published paper looking at outcomes after standardization of treatment for patients with perforated appendicitis, patients who received IV antibiotics (piperacillin-tazobactam or ertapenem) were also discharged home with oral antibiotics if a leukocytosis was not identified at time of discharge. Though perforation in this study was based on clinical impression of individual surgeon and not on strict objective criteria, they had similar rate of identification of postoperative abscess after discharge. In addition, readmission for treatment of postoperative abscess was 7% for patients within 30 days of original discharge [14]. In our study, identification of postoperative abscess after discharge was similar in both groups. Of the patients discharged home without PO antibiotics on the new protocol, 8.1% developed an intraabdominal abscess compared to 5.8% of those who were sent home with antibiotics. Although this was not statistically significant, the trend suggests potential undertreatment of patients with antibiotics that meet early discharge criteria, which should be verified with more data from other centers. Factors that can identify those patients predisposed to develop an abscess have yet to
be identified. With this lack of significant difference in outcomes and abscess formation however, there was a significant decrease in antibiotic utilization in postoperative setting with the initiation of the new protocol. 4. Conclusion Patients who meet 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, although this deserves validation through other studies. Institution of this new protocol has lead to significant decrease in postoperative antibiotic utilization. References [1] Chen C, Botello C, Cooper A, et al. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg 2003;196:212–21. [2] Rice-Townsend S, Barnes JN, Hall M, et al. Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children's hospitals: implications for value-based comparative analysis. Ann Surg 2014;259:1228–34. [3] St. Peter SD, Little DC, Calkins CM, et al. A simple and more cost-effective antibiotic regimen for perforated appendicitis. J Pediatr Surg 2006;41:1020–4. [4] Fraser JD, Aguayo P, Leys CM, et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg 2010;45:1198–202. [5] St. Peter SD, Adibe OO, Iqbal CW, et al. Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: a prospective randomized trial. Ann Surg 2012;256:581–5. [6] St. Peter SD, Sharp SW, Holcomb III GW, et al. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 2008;43:2242–5. [7] Schwartz MZ, Tapper D, Solenberger RI. Management of perforated appendicitis in children. Ann Surg 1983;197:407–11. [8] Lund DP, Murphy EU. Management of perforated appendicitis in children: a decade of aggressive treatment. J Pediatr Surg 1994;29:1130–4. [9] Strovoff MC, Totten M, Glick PL. PIC lines save money and hasten discharge in the care of children with ruptured appendicitis. J Pediatr Surg 1994;29:245–7. [10] Fishman SJ, Pelosi L, Klavon SL, et al. Perforated appendicitis: prospective outcome analysis for 150 children. J Pediatr Surg 2000;35:923–6. [11] Rice HE, Brown RL, Gollin G, et al. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. Arch Surg 2001;136:1391–5. [12] Adibe OO, Barnaby K, Dobies J, et al. Postoperative antibiotic therapy for children with perforated appendicitis: long course of intravenous antibiotics versus early conversion to an oral regimen. Am J Surg 2008;195:141–3. [13] Gollin G, Abarbanell A, Moores D. Oral antibiotics in the management of perforated appendicitis in children. Am Surg 2002;68:1072–4. [14] Slusher J, Bates CA, Johnson C, et al. Standardization and improvement of care for pediatric patients with perforated appendicitis. J Pediatr Surg 2014;49:1020–5.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Safety of a new protocol decreasing antibiotic utilization after laparoscopic appendectomy for perforated appendicitis in children: A prospective observational study Amita A. Desai, Hanna Alemayehu, George W. Holcomb III, Shawn D. St. Peter ⁎ Department of Surgery, Children's Mercy Hospital, Kansas City, MO
a r t i c l e
i n f o
Article history: Received 28 February 2015 Accepted 10 March 2015 Key words: Appendicitis Antibiotic Children Perforated
a b s t r a c t Introduction: 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. Methods: 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. Results: 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 b 0.001). Conclusions: 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. © 2015 Elsevier Inc. All rights reserved.
Practice patterns in the surgical and medical management of perforated appendicitis after antibiotics are widely variable [1,2]. At our institution, we commonly operate within 24 hours of presentation and length of intravenous antibiotic therapy has been evolving the past 8 years with the initiation of our first randomized trial that demonstrated once-daily dosing of ceftriaxone and metronidazole provides adequate antimicrobial therapy compared with previous traditional triple antibiotic therapy [3]. All of the patients received a minimum 5 days of intravenous (IV) antibiotic therapy. A second randomized trial of 100 patients was conducted comparing a minimum 5 day course of IV ceftriaxone and metronidazole to the opportunity to convert to oral (PO) antibiotics if clinically well prior to day 5 to complete a total of 7 days of combined therapy. This study found the conversion or oral antibiotics when able did not have an effect on risk of postoperative abscess [4]. We subsequently performed a third trial in 220 patients comparing irrigation to no irrigation during appendectomy in which all patients were managed with the management scheme of sending patients home with oral antibiotic when able [5]. This study found no ⁎ Corresponding author at: Department of Surgery, Children's Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO USA 64108. Tel.: +1 816 983 6465; fax: +1 816 983 6885. E-mail address: [email protected] (S.D. St. Peter). http://dx.doi.org/10.1016/j.jpedsurg.2015.03.006 0022-3468/© 2015 Elsevier Inc. All rights reserved.
differences in any outcomes. At this point we had 270 patients prospectively enrolled who were treated with the protocol of early conversion to PO antibiotics if clinically well prior to day 5 to complete 7 days combined therapy. In order to progress the protocol further, we conducted a prospective observational study in the next 270 patients admitted in which patients could be discharged home early without PO antibiotics if a leukocytosis is not identified at time of discharge prior to completion of a 5 day IV antibiotic course.
1. Methods After IRB approval (IRB #11120174), all children (Group 1) who underwent laparoscopic appendectomy for perforated appendicitis were prospectively observed from August 2011 to January 2014 with the institution of the new attenuated antibiotic regimen. These patients were compared to the patients enrolled in the 2 previous trials (Group 2) who received IV antibiotic therapy with PO antibiotics if discharged prior to day 5 [4,5]. Perforation was defined as hole in the appendix or fecalith in the abdomen as previously described [6]. Discharge criteria were met when patients were tolerating regular diet with pain controlled on oral pain medications and no fever
A.A. Desai et al. / Journal of Pediatric Surgery 50 (2015) 912–914
913
Fig. 1. Protocol used for 270 patients over 2 trials.
recorded over the previous 12 hours. Patients who met these criteria had a complete blood count drawn to evaluate for leukocytosis. Patients under the new study protocol (Group 1) received 50 mg/kg (max 2 g) IV ceftriaxone and 30 mg/kg (max 1 g) IV metronidazole every 24 hours. Patients who completed minimum 5 days of IV antibiotics were discharged home without oral antibiotics. Patients who met discharge criteria prior to 5 days, were discharged home with oral amoxicillinclavulanate for completion of 7-day antibiotic course if they had a leukocytosis on day of discharge. If leukocyte count was normal, regardless of differential counts, they were discharged without oral antibiotics. Patients under the old protocol in the comparison group (Group 2) also received daily dosing of IV ceftriaxone and metronidazole. All patients who met discharge criteria prior to completion of 5 days of IV antibiotics were discharged home with amoxicillin-clavulanate to complete 7 day course of antibiotics (Fig. 1) [4,5]. All patients in both groups received preoperative doses of ceftriaxone and metronidazole The outcome parameter compared between the two groups was abscess formation. Statistical evaluation performed between the two groups consisted of unpaired 2-tailed Student's t-test for continuous variables. Fisher exact and Chi-square with Yates correction were used for discrete variables where appropriate. 2. Results The new protocol reducing length of antibiotic therapy based on leukocyte count (Group 1) was used in 270 patients compared with 270 Table 1 Demographics of patients in receiving the new postoperative antibiotic protocol (Group 1) and previous protocol (Group 2) after laparoscopic appendectomy for perforated appendicitis.
Gender (M) Mean age (y) BMI Admission WBC Mean maximum temperature on admission
Group 1 (n = 270)
Group 2 (n = 270)
P
60 9.6 ± 3.8 19.2 ± 5.2 17.6 ± 5.7 37.7 ± 0.9
150 10 ± 3.9 19.8 ± 4.9 17.4 ± 5.8 37.9 ± 0.9
0.6 0.2 0.2 0.7 0.2
patients of previous protocol utilizing oral antibiotics to complete 7 day course if discharged early. There was no significant difference in patient demographics including gender, mean age, weight, height, or BMI as can be seen in Table 1. There was also no significant difference in objective measures at presentation including admission white blood cell (WBC) count or maximum temperature. No difference existed in operative time, time to regular diet intake, postoperative length of stay, or rate of abscess formation between the two groups. There was no difference in identification of postoperative abscess as inpatient and after discharge between the two groups. There was however a significant difference in number of patients discharged home on oral antibiotics without abscess identification prior to discharge. Of those patients who were not discharged home on oral antibiotics, there was no significant difference in rate of identification of postoperative abscess (Table 2). 152 patients in Group 1 were discharged before postoperative day 5. Of these 152 patients in the new protocol, 17 had an elevated leukocyte count and thus discharged home with PO antibiotics to complete 7 day course leaving 135 patients being discharged without antibiotics. 12 of these 152 patients (7.9%) were subsequently found to have an intraabdominal abscess. Of the 135 patients discharged home without PO antibiotics, 11(8.1%) were found to have a postoperative abscess after discharge. Only 1 (5.8%) of the 17 patients discharged home early with PO antibiotics was found to have a postoperative abscess. In Group 2, 136 patients were discharged before day 5 and all were given oral antibiotics. Of these patients 6 (3.9%) were subsequently found to have an abscess. Although this is not significant (P = 0.1), this difference could be more meaningful in a larger population (Table 3). Table 2 Outcomes of patients in receiving the new postoperative antibiotic regimen (Group 1) and previous postoperative antibiotic regimen (Group 2) after laparoscopic appendectomy for perforated appendicitis.
Operative time (min) Mean time to regular diet (hr) Mean postoperative length of stay Postoperative abscess Abscess diagnosed before discharge Abscess diagnosed after discharge
Group 1
Group 2
P-value
41.0 ± 18.6 83.2 ± 48.7 5.4 ± 2.9 59 (21.8%) 40 19 (7%)
41.6 ± 16.5 80.3 ± 37.9 5.4 ± 3.5 52 (19.3%) 34 18 (6.7%)
0.7 0.4 1.0 0.5 0.5 0.9
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A.A. Desai et al. / Journal of Pediatric Surgery 50 (2015) 912–914
Table 3 Patients discharged home prior to completion of 5 days IV antibiotic therapy.
Discharge home on PO antibiotics Postoperative abscess Postoperative abscess, on home PO antibiotics Postoperative abscess, without home PO antibiotics
New protocol group 1 (n = 152)
Old protocol group 2 (n = 136)
P-value
17 12/152 (7.9%) 1/17 (5.8%) 11/135 (8.1%)
136 6/136 (4.4%) 6/136 (4.4%) n/a
n/a 0.3 0.6 n/a
Patients who were discharged home prior to 5 days without PO antibiotics had a leukocyte count of 8.6 ± 2.4, and those discharged with PO antibiotics had a leukocytosis of 16.9 ± 3.5 (P b 0.001). When comparing these two groups, there was no significant difference in patient demographics.
3. Discussion Antibiotic therapy for treatment of perforated appendicitis has evolved over the past several decades. Traditionally, children were treated with up to 2 weeks of triple IV antibiotic therapy in attempt to prevent intraabdominal abscess formation [7,8]. This was followed by earlier discharge of patients home on IV antibiotics with use of PICC line with demonstration of similar efficacy with significant cost savings [9,10]. Since that time, it has been demonstrated in several studies that patients can be safely discharged home earlier on PO antibiotics when discharge criteria have been met [11–13]. In order to prevent interprovider variability, an evidence based definition of perforation as a hole in appendix or fecalith in abdomen used in previous prospective randomized trials was applied to the prospectively observed cohort after institution of the new protocol [6]. The overall incidence of postoperative abscess formation, after laparoscopic appendectomy did not significantly change under the new protocol. In a recently published paper looking at outcomes after standardization of treatment for patients with perforated appendicitis, patients who received IV antibiotics (piperacillin-tazobactam or ertapenem) were also discharged home with oral antibiotics if a leukocytosis was not identified at time of discharge. Though perforation in this study was based on clinical impression of individual surgeon and not on strict objective criteria, they had similar rate of identification of postoperative abscess after discharge. In addition, readmission for treatment of postoperative abscess was 7% for patients within 30 days of original discharge [14]. In our study, identification of postoperative abscess after discharge was similar in both groups. Of the patients discharged home without PO antibiotics on the new protocol, 8.1% developed an intraabdominal abscess compared to 5.8% of those who were sent home with antibiotics. Although this was not statistically significant, the trend suggests potential undertreatment of patients with antibiotics that meet early discharge criteria, which should be verified with more data from other centers. Factors that can identify those patients predisposed to develop an abscess have yet to
be identified. With this lack of significant difference in outcomes and abscess formation however, there was a significant decrease in antibiotic utilization in postoperative setting with the initiation of the new protocol. 4. Conclusion Patients who meet 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, although this deserves validation through other studies. Institution of this new protocol has lead to significant decrease in postoperative antibiotic utilization. References [1] Chen C, Botello C, Cooper A, et al. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg 2003;196:212–21. [2] Rice-Townsend S, Barnes JN, Hall M, et al. Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children's hospitals: implications for value-based comparative analysis. Ann Surg 2014;259:1228–34. [3] St. Peter SD, Little DC, Calkins CM, et al. A simple and more cost-effective antibiotic regimen for perforated appendicitis. J Pediatr Surg 2006;41:1020–4. [4] Fraser JD, Aguayo P, Leys CM, et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg 2010;45:1198–202. [5] St. Peter SD, Adibe OO, Iqbal CW, et al. Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: a prospective randomized trial. Ann Surg 2012;256:581–5. [6] St. Peter SD, Sharp SW, Holcomb III GW, et al. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 2008;43:2242–5. [7] Schwartz MZ, Tapper D, Solenberger RI. Management of perforated appendicitis in children. Ann Surg 1983;197:407–11. [8] Lund DP, Murphy EU. Management of perforated appendicitis in children: a decade of aggressive treatment. J Pediatr Surg 1994;29:1130–4. [9] Strovoff MC, Totten M, Glick PL. PIC lines save money and hasten discharge in the care of children with ruptured appendicitis. J Pediatr Surg 1994;29:245–7. [10] Fishman SJ, Pelosi L, Klavon SL, et al. Perforated appendicitis: prospective outcome analysis for 150 children. J Pediatr Surg 2000;35:923–6. [11] Rice HE, Brown RL, Gollin G, et al. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. Arch Surg 2001;136:1391–5. [12] Adibe OO, Barnaby K, Dobies J, et al. Postoperative antibiotic therapy for children with perforated appendicitis: long course of intravenous antibiotics versus early conversion to an oral regimen. Am J Surg 2008;195:141–3. [13] Gollin G, Abarbanell A, Moores D. Oral antibiotics in the management of perforated appendicitis in children. Am Surg 2002;68:1072–4. [14] Slusher J, Bates CA, Johnson C, et al. Standardization and improvement of care for pediatric patients with perforated appendicitis. J Pediatr Surg 2014;49:1020–5.
