Shiva Sharma, Breast/Endocrine S.H.O

Most common presentation requiring surgery

Great variability with regards to: Timing Choice Route of administration Instances of use

Perforated vs. Non-Perforated appendicitis

Pre-operative antibiotics Needed? Benefit vs. Cost Timing How long?

The use of antibiotics in perforated well est. Risk of intra-abdominal contamination Risk of abscess formation

Triple therapy previously Gram positive, Gram negative and

aerobic coverageBroad-spectrum single or double

agent therapy as effective

Morbidity Wound infection Intra-abdominal abscess

Timing of surgery Presenting with NPA progressing to

perforation Time of presentation to time of surgery Sepsis increases as appendicitis

progresses

Cost of antibiotics Monetary Risk of reaction Antibiotic related secondary infection Resistance

Cost of out of hours operatingHospital beds

Optimum duration of prophylactic antibiotics in non-perforated appendicitis

Following underwent emergency open appendicectomies Group A: single dose antibiotic pre-

operative Group B: Three dose/1 Day Group C: 5 day peri-operative course

Results: no significant impact on length of hospital stay

Wound infection rates▪ 6.5%, 6.4%, 3.6%

Increase in antibiotic related complications in the 5day group▪ 0%, 1.1%, 4.8%

▪ L.M. Mui etal. ANZ Journal of Surgery. 2005; 75:425

Timing of intervention does not affect outcome in acute appendicitis Retrospective study 1198 patients Mean time to surgery 7.1hr, range 1-

24hr Concluded: short delays from time to

surgery well tolerated

No relation between timing to surgical intervention and length of hospital stay

Complications more related to NPA vs. Perforated

Paper does not specify if antibiotics are used

Suggests that surgery can be delayed provided infection can be controlled

▪ C.Clyde etal; Am. Journal of Surgery (2008) 195; 590

Antibiotics and appendicitis in the pediatric population – Systematic Review Presented at the 2010 Meeting of the

American Pediatric Surgical Association Review of PubMed and other English

Literature up to 2009

Grade A evidence to support children should receive preoperative antibiotics

Cochrane review supports single dose preoperative antibiotics

Significant decrease in wound infection and intra-abdominal abscess

Grade B evidence to support single or double agent antibiotics in perforated cases

More effective, cost effective and similar rates as triple therapy

Total course of antibiotics should be 7 days Minimum 5 days IV

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee Systematic Review; S.L. Lee etal. Journal of Pediatric Surgery (2010) 45, 2181

Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendectomy Cochrane Database Syst Rev 2005;3

Donovan, I. A., D. Ellis, D. Gatehouse, G. Little, R. Grimley, S.Armstead, M. R. B. Keighley, and C. J. C. Strachan. 1979. One dose antibiotic prophylaxis against wound infection after appendectomy. A randomized trial of clindamycin, cefazolin sodium and a placebo. Br. J. Surg. 66:193-196.

Timing of intervention does not affect outcome in acute appendicitis. L.M. Mui etal. ANZ Journal of Surgery. 2005; 75:4

Timing of intervention does not affect outcome in acute appendicitis in a large community practice; The American Journal of Surgery (2008) 195, 590–593