Uselessness of microbiological samples in acute appendicitis with frank pus: to collect or not to collect?

Montuori, Mauro; Santurro, Letizia; Gianotti, Luca; Fattori, Luca

doi:10.1007/s00068-018-1031-7

Cited by 13 publications

(7 citation statements)

References 8 publications

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“…E. coli and S. anginosus were the most commonly cultured microorganisms in complicated appendicitis, mirroring our previous study and in line with other published studies [12,14,30,33,34]. Rate of infection with amoxicillinclavulanate-resistant E. coli remained similar to the last cohort (15% vs 14%).…”

Section: Discussionsupporting

confidence: 91%

Evidence-based optimisation of empirical antibiotic regimens in paediatric complicated appendicitis: a retrospective study of 94 patients

et al. 2022

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BACKGROUND: Acute appendicitis is the most frequent surgical emergency in the paediatric population. Complicated appendicitis accounts for 30% of cases and is inextricably linked to postoperative infectious complications. A study at our institution showed that amoxicillin-clavulanate resistant Escherichia coli in complicated appendicitis was significantly linked to postoperative infectious complications. These findings led to a change in the empirical antibiotic protocol (amoxicillin-clavulanate changed to ceftriaxone + metronidazole as of 2017), intending to reduce postoperative infectious complications in complicated appendicitis in our institution. AIM OF THE STUDY: This study aimed to analyse the microbiology and resistance profiles of pathogens of complicated appendicitis at our institution since implementing the new antibiotic protocol and the postoperative infectious complications rate. METHODS: We designed a retrospective comparative cohort study. During the defined study period (01 January 2017 to 31 July 2020), medical records were analysed for cases of acute appendicitis, complicated appendicitis and postoperative infectious complications, retaining only those who fulfilled inclusion criteria. Postoperative outcomes, microbiology and antibiotic resistance of peritoneal swabs were analysed. RESULTS: During the study period, 95 patients presented with a complicated appendicitis, and 11 (12%) developed postoperative infectious complications. The most frequent pathogens found in complicated appendicitis were E. coli (66%), Streptococcus anginosus (45%), and Bacteroides fragilis (22%). Pseudomonas aeruginosa was present in 17% of complicated appendicitis. Pathogens involved in postoperative infectious complications mirrored the distribution found in complicated appendicitis without postoperative infectious complications. Antibiotic susceptibility analysis showed that 10 (15%) of E. coli strains were resistant to amoxicillin-clavulanate but sensitive to ceftriaxone + metronidazole, with only one strain responsible for causing a postoperative infectious complication. Six additional strains of E. coli (9%) were resistant to amoxicillin-clavulanate and our empirical antibiotic regimen but were not associated with an increase in postoperative infectious complications. Compared with our previous study, there was a decrease in postoperative infectious complications from 16% to 12%. Postoperative infectious complications caused by amoxicillin-clavulanate-resistant E. coli decreased from 28% to 9%. CONCLUSION: This retrospective study demonstrated a decrease in the rate of postoperative infectious complications due to amoxicillin-clavulanate-resistant E. coli in complicated appendicitis. These findings accentuate the need to implement evidence-based treatment protocols based on local microbiology profiles and resistance rates to optimise post-operative antibiotics in complicated appendicitis.

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Section: Discussionsupporting

confidence: 91%

Evidence-based optimisation of empirical antibiotic regimens in paediatric complicated appendicitis: a retrospective study of 94 patients

et al. 2022

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“…Indeed, an escalation of the antimicrobial therapy, tailored to the microbiological results, did not prevent abscess formation in both the adult and pediatric population. 18,19 This consideration was further supported by our findings. In the ECA group, the presence of the abdominal drain did not reduce the rate of failure of the first-line therapy.…”

Section: Discussionsupporting

confidence: 88%

Complicated acute appendicitis in children: the importance of stewarding antibiotic prescriptions

Ghidini¹,

Virgone²,

Donà³

et al. 2022

Turk J Pediatr

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Background. The aim was to assess the success of a three-drug regimen, consisting of cefazoline, metronidazole and gentamicine, for the antimicrobial treatment of complicated appendicitis and to investigate predictors of failure. Methods. This retrospective study included patients who had undergone appendectomy for complicated appendicitis from 2013 to 2018. The shift to second-line antibiotics was considered a failure. The choice was based upon clinical deterioration. Patients were grouped into 2 groups: localized complicated appendicitis (LCA) and extensively complicated appendicitis (ECA) for the study purpose. Univariate and multivariate analysis were performed to identify predictors of failure. Results. Ninety patients (65.2%) with LCA and 48 patients (35%) with ECA were included. Three-drug regimen failed in 50 patients (36%) with a higher rate in the ECA group (50%, p=0.017). In a multivariate analysis, this failure was found to be associated with ECA (adjusted OR 3.00 [1.2-7.4], p=0.041). Children with ECA experienced a longer hospital stay (median length 8 days, p &lt; 0.001) and antimicrobial therapy (median length 8 days, p &lt; 0.001). However, no difference in the rate of surgical site infections was found (p=0.514). Conclusions. The institutional antibiotic stewardship program highlighted a high failure rate for the old threedrug regimen. A new protocol should be recommended, especially for the patients affected by ECA.

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“…Two main philosophies can be identified in the antibiotic regimens used to cover organisms that form intraabdominal abscesses (IAA) after complicated appendicitis: (1) to cover the most common pathogens empirically and change antibiotics based on clinical deterioration, or according to cultures from the abscess if an IAA forms, and (2) to start empiric treatment and send cultures from the primary operation and change antibiotics to cover organisms found in the cultures. This intraoperative swabbing of the peritoneum to identify resistant organisms is controversial [2–5], and was reviewed by Davies et al [6]. It is not certain that the dominating organisms found initially are those that establish abscesses, and several smaller series indeed show a large discrepancy between intraoperative and IAA cultures [7–10], and some data suggests that guiding antibiotics by peritoneal swabs gets even worse results than empiric broad-spectrum antibiotics [9].…”

Section: Introductionmentioning

confidence: 99%

Intraoperative cultures during appendectomy in children are poor predictors of pathogens and resistance patterns in cultures from postoperative abscesses

et al. 2019

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Background Intraoperative cultures are commonly sent in complicated appendicitis. Culture-guided antibiotics used to prevent postoperative infectious complications are debated. In this study, we describe the microbial overlap between intraoperative and abscess cultures, and antibiotic resistance patterns. Method A local register of a children’s hospital treating children 0–15 years old with appendicitis between 2006 and 2013 was used to find cases with intraoperative cultures, and cultures from drained or aspirated postoperative intraabdominal abscesses. Culture results, administered antibiotics, their nominal coverage of the identified microorganisms, and rationales given for changes in antibiotic regimens were collected from electronic medical records. Results In 25 of 35 patients who met inclusion criteria, there was no overlap between the intraoperative and abscess cultures. In 33 of 35 patients, all identified intraoperative organisms were covered with postoperative antibiotics. In 14 patients, organisms in the abscess culture were not covered by administered antibiotics. Enterococci not found in the intraoperative culture were found in 12 of 35 abscesses. We found no difference in the antibiotic coverage between rationales given for antibiotic changes. Conclusion The overlap between intraoperative cultures and cultures from subsequent abscesses was small. Lack of antibiotic coverage of intraoperative cultures was not an important factor in abscess formation. Electronic supplementary material The online version of this article (10.1007/s00383-018-04428-3) contains supplementary material, which is available to authorized users.

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Uselessness of microbiological samples in acute appendicitis with frank pus: to collect or not to collect?

Cited by 13 publications

References 8 publications

Evidence-based optimisation of empirical antibiotic regimens in paediatric complicated appendicitis: a retrospective study of 94 patients

Evidence-based optimisation of empirical antibiotic regimens in paediatric complicated appendicitis: a retrospective study of 94 patients

Complicated acute appendicitis in children: the importance of stewarding antibiotic prescriptions

Intraoperative cultures during appendectomy in children are poor predictors of pathogens and resistance patterns in cultures from postoperative abscesses

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