37 Purulent and gangrenous appendicitis: No perforation = No antibiotics
Rebecca West, Olugbenga Awolaran, Richard Lindley
Sheffield Children's Hospital, Sheffield, United Kingdom

Abstract

Aim

Children frequently have appendicitis with frank intra-peritoneal pus or gangrene without perforation. There is significant variance among surgeons/centres with use of post-operative antibiotics. This before & after study compared outcomes between routine post-op IV antibiotics versus no post-op antibiotics in a regional paediatric surgical centre for paediatric purulent or gangrenous appendicitis.

Method

Operative records and clinical notes were retrospectively reviewed of all consecutive paediatric emergency open and laparoscopic appendicectomies (0-16 years), between May 2015 and October 2017. In the first year most non-perforated but purulent and/or gangrenous appendicectomies were given five days post-op antibiotics. A strict definition of appendicitis was then introduced and a recommendation that only perforated cases should receive post-operative antibiotics. Perforated appendicitis was defined as a visible feacolith or hole in the appendix or caecum. The main outcomes compared between these two groups were post-operative abscess rates, readmissions and length of stay.

Results

233 emergency appendicectomies were performed. 44 (19%) were macroscopically non-perforated but had frank pus and/or gangrene (Table 1), 75 (32%) were perforated appendicitis and 114 (49%) simple appendicitis.  

Table 1: Outcomes for paediatric non-perforated appendicitis with pus and/or gangrene.

Outcomes

Continued antibiotics post-op

No post-op antibiotics

p-value

Number

29

15

 

Average POD at full oral intake

3.2

2.5

 

Intra-abdominal collection

14% (4/29)

7% (1/15)

0.49

Average length of hospital stay (days)

5.8

3.3

 

Readmission

14% (4/29)

7% (1/15)

0.49

Perforation reported on histology

41% (12/29)

20% (3/15)

 

Positive peritoneal pus culture

9/10 (90%)

6/9 (67%)

 

Conclusion

  • This study showed no adverse effects of withholding routine post-operative antibiotics in paediatric purulent or gangrenous non-perforated appendicitis.
  • Clear operative documentation of perforation is vital to guide post-operative management. Operative description correlated better with clinical outcome than histology or microbiology report. 

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