Antibiotics for Appendicitis:When are they needed?

January 13, 2018Dr. Mahmoud M. Al RifaaiConsultant of pediatrics , PEC

Disclosure

I do not have any relevant financial relationship with commercial interest to disclose.

Learning Objectives

Analyze evidence for use and timing of antibioticsin the management of appendicitis.

Pathophysiology§ Luminal obstruction § Subsequent localized venous ischemia§ Mucosal disruption§ Invasive bacterial infection§ Localized inflammation§ Progress to necrosis and possible

gangrene and perforation

Appendicitis classification

Early appendicitis

Advanced appendicitis

Appendicular mass or intra abdominal abscess

Appendectomy standard treatment for all types

Antibiotics indicated for perforated appendicitis

What is the role of antibiotics in management of early appendicitis ?

Management of pediatric appendicitis

Prophylactic antibiotics +Surgical management for Early appendicitis

§ Antibiotics effective in preventing post op. complication § A single prophylactic dose of (BS) antibiotics as soon as

the diagnosis established and at least 30 min before the incision .

Meta analysis study (539 children) .AU :United Kingdom National Surgical Research Collaborative, Bhangu SO : Ann Surg. 2014;259(5):894.

Antibiotics as Non operative treatment (NOT) for Early appendicitis

May be an option for selected patients depend on care giver preference with :●Abdominal pain for <48 hours●WBC ≤18,000/micro L●Normal CRP●No appendicolith present on imaging●Appendix diameter ≤1.1 cm on imaging●No concern for rupture based upon clinical findings

(NOT) For early appendicitis

Table

M

No.of patients

(NOT)successF/U periodRecurrence

413

88-99%8wks -4 yrs.

15%

168

73- 91%1 m- 1 yr.

22%

197

87%

18 m

NA

Meta analysis -1 Study -3Meta analysis -2

GeorgiouR,etal.Pediatrics.2017

HuangL,etal.JAMAPediatric.2017

SteinerZ,et alEur JPediatr.2017

Antibiotic protocols (NOT) for Early appendicitis

. vary widely but typically include : 1-2 days inpatient iv (BS)antibiotics until resolution of symptoms followed by oral antibiotics as outpatient.

Summary

Ø Early appendicitis in children needs appendectomy .Ø A single prophylactic dose of a broad spectrum antibiotic before operation is recommended .Ø NOT may be appropriate in selected patients with features of early appendicitis .

References

. 1-United Kingdom National Surgical Research Collaborative, Bhangu A. Safety of short, in-hospital delays before surgery for acute appendicitis: multicentre cohort study, systematic review, and meta-analysis. Ann Surg 2014; 259:894.2-Georgiou R, Eaton S, Stanton MP, et al. Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis. Pediatrics 2017; 139.3-Huang L, Yin Y, Yang L, et al. Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis. JAMA Pediatr 2017; 171:4264-SteinerZ,BuklanG,StackieviczR,etal.Conservativetreatmentinuncomplicatedacuteappendicitis:reassessmentofpracticesafety.EurJPediatr2017;176:521

Thank you