Appendicitis Research Today is a free monthly online journal that collates and summarizes the latest research about Appendicitis, including details on symptoms, surgery, causes, treatment. | ||||||||
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Minimum postoperative antibiotic duration in advanced appendicitis in children: A review.Schmittenbecher P
Antibiotic treatment is standard after appendectomy for gangrenous or perforated appendicitis, but evidence is limited. A standard regimen should be characterized by a minimum duration to be cost-effective, prevent bacterial resistance, minimize toxicities and increase patient compliance. It was the aim of this review to determine a suitable standard for length of antibiotic administration. The objective was to determine if more than 3 days of treatment improves outcome for advanced appendicitis, relative to 3 days or less. Additional questions asked for the suitable minimum duration of antibiotic use, for an appropriate standard for discharge, for a standard for modification of therapy from intravenous to oral, and for criteria to discontinue the therapy. The analysis included studies of antibiotic use in children who had undergone appendectomy for gangrenous or perforated appendicitis. Data on duration of antibiotic use, on antibiotic vs. placebo, on two or more antibiotics, on parenteral or oral administration and on inpatient or outpatient treatment were selected. The studies had to include at least one key outcome parameter "postoperative wound infection" or "abdominal abscess/infection". Twenty-eight studies published between 1980 and 2002 and meeting the inclusion criteria were found by Medline search, Cochrane database analysis, and from bibliographies of recent reviews and personal files. The studies comprised 2284 children. Shortest duration of antibiotic therapy was 3 days. An increased number of infectious complications was not found compared to a longer treatment period. Antibiotics were stopped based on a protocol (10 studies), on a variable base (surgeon's discretion, clinical findings, afebrile; 18 studies) or on leucocytosis (7 studies). These criteria were criticized because the persistence of signs of inflammation is not an indication to continue, re-start or change antibiotics. There is no agreement concerning discharge criteria. Free of medications, afebrile and with a normal white cell count were mentioned in two papers. No study discharged a child to outpatient antibiotic therapy earlier than the 4th postoperative day. Monotherapy with a 2nd generation cephalosporin alone was judged as less expensive, safe and effective. Therefore, the combination with aminoglycosides should be reserved for resistant organisms and nosocomial infections. Peritoneal cultures seemed unnecessary for guiding therapy. Limits of the review were that the studies had related, but not identical purposes. Often dosages of antibiotics were not given. Differences in operative techniques and topical wound treatment were not considered. In conclusion, early discharge to a longer oral outpatient therapy is sensible if cost-effectiveness has priority. Shorter antibiotic courses, but longer inpatient observation prevent bacterial resistance and minimizes drug toxicity. It should be stated that unjustified fear of treatment failure and a noticeable lack of interest with regard to discerning whether less is better allowed some of the initial questions to go unanswered. Published 21 July 2005 in J Pediatr Surg, 40(7): 1216.
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