The Care of Appendicular Peritonitis in the Era of Antibiotic Resistance: The Role of Surgery and the Appropriate Antibiotic Choice

Abstract

Purpose: Acute appendicitis (AA), classified as non-complicated acute appendicitis (NCAA) and complicated acute appendicitis (CAA), is the most common cause of abdominal pain in children requiring surgical treatment. If the first-line treatment for NCAA is to be debated between conservative management and surgery, authors find a consensus in choosing surgery as the first step for CAA in children. In the case of patients with CAA undergoing surgery, a broad-spectrum antibiotic therapy should be administered to reduce the risk of post-operative complications (POC). The rise in antibiotic resistance requires a review of recent data regarding bacterial species involved in AA. The primary aim of our study was to investigate the clinical effectiveness of different antibiotic protocols in patients undergoing surgery for CAA. The secondary aim was to verify the antibiotic’s in vitro effectiveness based on cultural examinations. Methods: A retrospective and prospective study was conducted on all patients operated on at our pediatric surgery department for CAA from January 2017 to January 2023. The following data were collected: age at surgery, sex, surgical technique, duration of the procedure, antibiotic therapy, duration of the hospital stay, cultural examination of peritoneal effusion, and POC. Results: We divided the patients enrolled (n = 182) into three groups of antibiotic protocols; only one group resulted in a statistically significant lower rate of POC. Different pathogens were isolated (Enterobacteriaceae, non-fermentative Gram-negative bacilli, anaerobes, Gram-positive cocci), and the in vitro rate of antimicrobial sensitivity varied from 40% to 94% in the three groups of patients. Conclusions: Based on cultural examinations, our study showed a high rate of inadequacy regarding the therapy with amoxicillin + clavulanic acid despite a low rate of complications. Radical surgery seems to be the best way to reduce complications in children with CAA.