title: Prophylactic antibiotics in uncomplicated appendicitis during childhood--a prospective randomised study. The efficacy of postoperative oral antibiotics in appendicitis: a randomized prospective double-blinded study. A controlled study of single dosage cefamandole in the prophylaxis of wound infections in appendectomy. Wound infection in emergency appendicectomy: A prospective trial with topical ampicillin and antiseptic solution irrigation Prophylactic interparietal povidone‐iodine in abdominal surgery A double-blind controlled trial of metronidazole suppositories in children undergoing appendicectomy. Tinidazole in the prophylaxis of post-appendicectomy infections. A controlled trial of intraperitoneal noxytiolin in perforated appendicitis Should prophylactic antibiotics be given perioperatively in acute appendicitis without perforation? [Preventive use of single dose antibiotics in acute appendicitis. Results of a prospective randomized clinical study]. One‐dose antibiotic prophylaxis against wound infection after appendicectomy: A randomized trial of clindamycin, cefazolin sodium and a placebo The influence of metronidazole prophylaxis and the method of closure on wound infection in non-perforating appendicitis in childhood. Primary appendectomy. The effect of prophylatic cephaloridine on postoperative wound infection. The place of antibiotics in the prevention of post-appendicectomy sepsis: a prospective study of 400 cases. Systemic prophylaxis with gentamicin-metronidazole in appendicectomy and colorectal surgery: a prospective controlled clinical study. Single-dose intraoperative antibiotic prophylaxis in emergency abdominal surgery. The reduction of surgical wound infections by prophylactic parenteral cephaloridine a controlled clinical trial Metronidazole prophylaxis in acute mural appendicitis: failure of a single intra-operative infusion to reduce wound infection. [Prospective study on the prevention of wound infections after appendectomy for acute appendicitis]. A double‐blind trial of a single intravenous dose of metronidazole as prophylaxis against wound infection following appendicectomy [General or individually calculated preventive antibiotic administration. Summary of the Magdeburg appendicitis study]. Management of wound infection after appendectomy: are parenteral antibiotics useful? Single-dose intrarectal metronidazole prophylaxis against wound infection after appendectomy. The effect of topical povidone‐iodine on the incidence of infection in surgical wounds Prophylactic metronidazole in appendectomy: a double-blind controlled trial. The necessity of prophylactic antibiotics in uncomplicated appendicitis during childhood. Antiseptic wick: Does it reduce the incidence of wound infection following appendectomy? Acute nonperforating appendicitis. Efficacy of brief antibiotic prophylaxis. Effect of Prophylactic Antibiotics in Acute Nonperforated Appendicitis: A Prospective, Randomized, Double‐blind Clinical Study Antibiotic Prophylaxis in Acute Nonperforated Appendicitis: The Danish Multicenter Study Group 111 Gangrenous and perforated appendicitis with peritonitis: treatment and bacteriology. Tinidazole prophylaxis in appendicectomies. A controlled study of single-dose versus 3-day therapy. Prophylactic metronidazole in prevention of infection after appendicectomy: report of a double-blind trial. A randomized prospective trial comparing the value of intravenous and preincisional cefamandole in reducing postoperative sepsis after operations upon the gastrointestinal tract. Complicated appendicitis: is there a minimum intravenous antibiotic requirement? A prospective randomized trial. The prevention of post-appendicectomy sepsis by metronidazole and cefazolin: a controlled double blind trial. Nonperforative appendicitis: a continuing surgical dilemma. [Perioperative antibiotic prophylaxis with cefamandole before appendectomy. A prospective randomized double-blind study]. Metronidazole prophylaxis against wound infection in patients undergoing appendicectomy. Prophylaxis of wound infection. Irrigation of the peritoneal cavity with cephalothin. SINGLE-DOSE PEROPERATIVE ANTIBIOTIC PROPHYLAXIS IN GASTROINTESTINAL SURGERY CLINICAL AND ECONOMIC CONSEQUENCES OF WOUND SEPSIS AFTER APPENDICECTOMY AND THEIR MODIFICATION BY METRONIDAZOLE OR POVIDONE IODINE The value of a single intravenous dose of metronidazole as prophylaxis against wound infection after appendicectomy. The effect of a single‐dose parenteral antibiotic in the prevention of wound infection a controlled trial Use of prophylactic antimicrobial drugs to prevent postoperative wound infections. Timing of antibiotic treatment in non-perforated gangrenous appendicitis. Topical ampicillin in the prevention of wound infection after appendicectomy Intrarectal metronidazole in the prevention of anaerobic infections after emergency appendicectomy: A controlled clinical trial The prevention of postappendicectomy sepsis by metronidazole and cotrimoxazole: a controlled double blind trial. Prevention of wound infection after appendicectomy. Metronidazole in prevention and treatment of bacteroides infections after appendicectomy. Wound infection following appendicectomy: The effect of extraperitoneal wound drainage and systemic antibiotic prophylaxis Prophylactic metronidazole in appendicectomy: A controlled trial Prophylactic lincomycin in the prevention of wound infection following appendicectomy: A double blind study Single dose intra‐rectal metronidazole as prophylaxis against wound infection following emergency appendicectomy Single-dose parenteral antibiotic prophylaxis in gastrointestinal surgery. Prevention of post-operative infection in appendicectomy by single dose intravenous metronidazole. An open prospective randomised study. Prophylactic cephalothin in gastrointestinal surgery.
abstract: 544 children operated upon for uncomplicated appendicitis were r and omised into three groups . Group I received no antibiotics , patients in Group II were administered one single pre-operative dose of metronidazole ( 10 mg/kg ) and patients in Group III received both both metronidazole ( 20 mg/kg ) and cefuroxime ( 50 mg/kg ) in a single preoperative dose . The rate of infectious complications in Group I was 6.3 % but only 2.1 and 2.3 in Groups II and III , respectively . Among patients with a normal appendix or patients with simple appendicitis there was no difference in the rate of post-operative infections between the three different groups . However , in patients with gangrenous appendicitis the rate of postoperative infections was significantly lower in the two groups who received preoperative antibiotics ( 1.8 % and 3.0 % respectively ) than in the group receiving no prophylactic antibiotics ( infection rate 14 % ) . It is concluded that a single preoperative dose of metronidazole significantly decreases the rate of postoperative infectious complications in children with appendicitis . No further improvement could be demonstrated if cefuroxime against aerobic organisms was added The conventional treatment of acute appendicitis is appendectomy followed by intravenous ( IV ) antibiotics until intraabdominal infection has resolved . It is controversial as to whether it is efficacious to add a course of oral antibiotics after cessation of IV antibiotics . All consenting patients who presented to Kern Medical Center between October 2000 and June 2003 with acute appendicitis were entered into the study . Perforated/gangrenous appendicitis was equally represented in the two study arms . After appendectomy , and when IV antibiotics were ready to be discontinued , patients were r and omized to receive a 7-day outpatient course of either placebo ( Group 1 ) or oral antibiotics ( Group 2 ) . Patients were monitored for infectious complications for a minimum of 3 months , and there was no statistical difference ( 11.5 % in Group 1 vs 12.1 % in Group 2 , P = 0.61 ) . The data suggest that adding a course of outpatient oral antibiotics  , after completing a course of IV antibiotics , does not decrease postoperative infectious complications in appendicitis patients A series of 102 consecutive patients undergoing appendectomy through an incision in the right iliac fossa entered a prospect i ve r and omized trial to compare the effects of a 2 gram intravenous bolus dose of cefam and ole with a control study . No differences occurred in the incidence of wound infection in the two groups . We conclude that there is no place for a single preoperative dosage of cefam and ole in the management of appendicitis A r and omized controlled trail in 374 patients requiring emergency appendicectomy  to determine the value of topical ampicillin and antiseptic solution of chlorhexidine and cetyl trimethyl ammonium bromide ( Savlon ) in preventing wound infection is reported . The application of 1 g of ampicillin powder to the wound significantly reduced wound infection in perforated appendicitis , but not in unperforated appendicitis . Wound irrigation with 1 per cent cetyl trimethyl ammonium bromide was ineffective in preventing wound infection in all grade s of appendicitis . When wound contamination is difficult to avoid , as in perforated appendicitis , topical ampicillin should be used to reduce the rate of wound infection This study sought to determine in a district general hospital ( a ) the frequency and nature of bacterial contamination at operation , ( b ) the incidence of consequent infection and ( c ) the prophylactic effect , if any , of inter‐parietal povidone‐iodine against postoperative wound infection A total of 133 children , aged 16 months to 15 years ( mean 6.7 years ) , with presumptive acute appendicitis , was included in a double-blind , placebo-controlled trial of the short-term ( 72 hour ) use of metronidazole suppositories as prophylaxis against post-operative infection . There was no significant difference in the incidence or severity of wound infection or post-operative intra-abdominal sepsis between the metronidazole-treated and placebo groups . It is suggested that intra-rectal metronidazole , when used exclusively , is not sufficient for effective prophylaxis for appendicitis in childhood A total of 223 consecutive suspected appendicitis patients were treated preoperatively with parenteral tinidazole or physiological saline ( control group ) . An infusion of 500 mg tinidazole was given to 110 patients over 30 minutes beginning about 30 minutes before the start of the operation , the control group comprised 111 patients .  Postoperative infections were diagnosed in three patients in the group receiving tinidazole ( 3 % ) and in 17 patients in the control group ( 15 % ) . The difference was statistically significant . There were no side-effects due to the drugs . Tinidazole appears to be well suited to the prophylaxis of post-appendicectomy infections A controlled trial of intraperitoneal noxytiolin ( Noxiflex ) solution in patients with peritonitis due to perforafed appendicitis is reported . No significant difference was found in the incidence of complications between the treated and a control group , raising doubts as to whether this substance is of value when used intraperitoneally in peritonitis The authors question the need to give prophylactic antibiotics perioperatively in all cases of acute appendicitis without perforation to reduce the rate of wound infection . A retrospective study of 82 patients showed a wound infection rate of 4.8 % ; 3 of 53 patients who did not receive antibiotics  had a wound infection compared with 1 of 29 patients who received antibiotics . A prospect i ve double-blind clinical trial was performed comparing the results of perioperative administration of cefam and ole and placebo . One of 21 patients who received the placebo had a wound infection ; none of the 21 patients given cefam and ole had infection . Thus , the authors conclude that , although reports in the literature suggest that antibiotics given perioperatively decrease the rate of wound infection  in acute appendicitis without perforation , the incidence of such infection is too low to warrant routine administration . They suggest that such antibiotic use be reserved for those suspected of having more serious disease A prospect i ve r and omized clinical trial was performed to determine the efficiency of single-dose antibiotic prophylaxis in preventing septic complications after appendectomy . The infection rate increased significantly in the control group without antibiotic prophylaxis ( 9.3 % to 20.3 % ) . Older patients with severe appendicitis had more advantages from the prophylaxis than younger ones . We have suggested to perform antibiotic prophylaxis individually only in those patients with high risk of septic complications after appendectomy Two hundred and fifty patients were admitted to a prospect i ve r and omized trial of single dosage prophylaxis against wound infection after appendicectomy . There were 12 exclusions , 72 patients received placebo , 81 received 600 mg i.m . clindamycin phosphate and 85 received 1 g i.m . cefazolin sodium , the agent being given in the anaesthetic room . Clindamycin produced a significant reduction in the overall rate of wound infection from 33 per cent in the controls to 17 per cent . In cases with a gangrenous or perforated appendix the infection rate in controls was 78 per cent ; this was reduced to 44 per cent by a single dose of clindamycin Prospect i ve investigation of consecutive children suffering from non-perforating appendicitis indicated that metronidazole prophylaxis significantly reduces the risk of postoperative wound sepsis regardless of the method of closure . However , in view of the advantages of subcuticular polyglycolic acid this must be regarded as the method of closure of choice in non-perforating appendicitis in children A prospect i ve , r and omized , double-blind study on the effect of cephaloridine prophylaxis in the surgical management of appendicitis was performed . Of the 139 patients studied , 70 received cephaloridine and 69 received placebo prophylaxis . Both groups of patients were well matched with regard to age , sex , operative findings , and bacteria isolated at operation . Postoperative wound infections were detected in 11.6 % of placebo-treated patients and in 1.4 % of cephaloridine-treated patients ( P less than .02 ) . Prophylactic treatment with cephaloridine of patients undergoing surgery for uncomplicated appendicitis result ed in a perceptible reduction in the rate of postoperative wound infection Post-appendicectomy sepsis still causes considerable morbidity and prolongs hospital stay . A large amount of recent work has gone into attempts to reduce such problems using various topical and systemic agents in differing regimes , with wide variation in their results . The aim of our study was to examine further the effectiveness of those different lines of prophylaxis against placebo in reducing post-appendicectomy sepsis . It is a comparative study of 400 cases of uncomplicated appendicitis operated upon by three senior Surgeons . The cases were allocated r and omly in equal number to four groups according to the prophylactic antibiotic regime used : ( a ) Placebo ; ( b ) Metronidazole alone ; ( c ) Metronidazole and cefazolin ; ( d ) Metronidazole and tobramycin . Antibiotics were given preoperatively with premedication and continued postoperatively for three days . The patients were checked for signs of sepsis during hospital stay and weekly up to a minimum of four weeks after discharge . They were also compared as far as their hospital stay is concerned . The conclusion of this study is that a combination of an antibiotic aim ed at aerobes ( cefazolin or tobramycin ) with another aim ing at anaerobes ( metronidazole ) is the best prophylactic regime against post-appendicectomy sepsis A prospect i ve , r and omized , clinical study was carried out in 188 patients undergoing appendicectomy or colorectal surgery  to test the efficacy of prophylactic , parenterally-administered antibiotics in the prevention of infection . The results show the effectiveness of the association gentamicin-metronidazole  ( 9.4 % of infections ) , compared to the control group with no antibiotics ( 39.1 % of infections ) , X2 = 14.1 ; P less than 0.001 ) In a r and omized controlled trial of the use of a single intravenous dose of gentamicin sulfate and clindamycin phosphate used intraoperatively during emergency abdominal surgery , the overall incidence of postoperative wound infection was reduced from 32.3 % to 10.4 % . Significant reduction in wound infection occurred in the study group compared with control subjects irrespective of the underlying pathologic lesion . No side effects of the use of antibiotics were noted . The policy of antibiotic prophylaxis in emergency surgery seems to be of particular benefit in elderly patients In a series of 762 general surgical wounds 376 were selected at r and om to receive three parenteral doses of cephaloridine and 386 remained as untreated controls . In all types of operation , with the exception of wounds in the lower extremities associated with arterial surgery , the rate of wound infection was lowered by the prophylactic use of cephaloridine . The results were statistically significant for total wounds , clean wounds , total contaminated wounds , and contaminated wounds other than in colorectal surgery . We therefore recommend the routine use of three doses of cephaloridine The efficacy of a single 500 mg intravenous intra-operative dose of metronidazole in the prevention of postoperative wound infection , following appendicectomy for acute mural appendicitis , was studied in a prospect i ve r and omized placebo controlled trial . Fourteen of the 96 patients ( 14.6 % ) in the metronidazole group and 13 of the 94 in the  placebo  group ( 13.8 % ) developed postoperative wound infection . Late sepsis was noted in 4 out of the 96 patients in the metronidazole group and in one of the 94 patients in the placebo group . This study suggests that a single intra-operative dose of metronidazole dose not reduce the incidence of postoperative wound infection following appendicectomy for acute mural appendicitis In the search for an appropriate antibiotic to reduce the rate of  postoperative wound infection in patients with acute appendicitis , we have r and omized 150 patients preoperatively in a prospect i ve 3-arm study . The operation technique was st and ardized for all patients and involved the use of plastic wound protectors . Bacterial contamination was documented by 3 swabs taken during operation . In 2 arms , patients received short-term adjuvant prophylaxis with either cefazolin or clindamycin/tobramycin . The third arm served as a control . Wound contamination ws proven in 33 % of all cases but only 4 % developed a real wound infection . The rate of infection was almost identical in all groups , without a statistically significant difference in the chi2 test . It is concluded that wound infection after appendectomy can not be prevented by prophylactic use of antibiotics . Careful operation technique with local protective steps is quite sufficient . Antibiotics should therefore be reserved for special indications One hundred patients undergoing appendicectomy through a right iliac fossa incision were r and omized to receive normal saline or 500 mg metronidazole as an intravenous infusion during the operation . One patient in the saline group developed an erythcmatous rash . There were 13 wound infections ( as defined by the discharge of pus ) , 12 ( out of 51 ) in the saline group and 1 ( out of 49 ) in the metronidazole group . Bacteroides spp . were frequently cultured from the lumen of removed appendices and from pus obtained from infected wounds . This work supports the value of metronidazole but suggests that a single‐dose regimen is adequate for prophylaxis A prospect i ve r and omized clinical trial was performed to determine the efficiency of single-dose antibiotic prophylaxis in preventing septic complications after appendectomy . The infection rate increased significantly in the control group without antibiotic prophylaxis ( 9.3 % to 20.3 % ) . Older patients with severe appendicitis had more advantages from the prophylaxis than younger one . We have suggested to perform antibiotic prophylaxis individually only in those patients with high risk of septic complications after appendectomy This study investigated the use of antibiotics in the treatment of wound infections after appendectomy . The subjects were 72 patients with post-operative wound infections at a district general hospital in Jordan . All patients received daily antiseptic dressings with povidone-iodine 10 % in alcohol . The patients were r and omized in a single-blind trial to receive either no antibiotics or parenteral antibiotics metronidazole and cefoxitin . There was no significant effect of antibiotic use in patients with early inflamed or severely inflamed appendicitis . However , for patients with perforated appendicitis the mean length of hospital stay and the mean frequency of change of dressings were significantly reduced . We conclude that antibiotics do not offer any advantage in post-appendectomy wound infections except for cases of perforated appendix Abstract In a prospect i ve , r and omized , nonblind clinical trial , single-dose intrarectal metronidazole prophylaxis reduced significantly ( A r and omized stratified clinical trial of topical povidone‐iodine in 627 patients undergoing abdominal procedures demonstrated a reduction in postoperative wound sepsis  in female patients , in patients receiving subcutaneous low dose  heparin and during the first quarter of the trial when the infection rate in control subjects was high . Overall , there was no significant reduction in wound sepsis after administration of povidone‐iodine due mainly to a high infection rate in povidone‐iodine treated male appendix operations where , by chance , there was an increased incidence of contamination with Bacteroides fragilis Ninety-eight patients with suspected nonperforated acute appendicitis have to date been entered into a continuing , prospect i ve , blinded r and omized trial to determine the role of prophylactic metronidazole in postoperative wound infection . Twenty-six patients were excluded for the following reasons : diagnosis other than acute appendicitis ( 16 ) , perforation of the appendix ( 8) , administration of other antibiotics ( 1 ) , and refusal to enter study ( 1 ) . Seventy-two patients , 47 men and 25 women , with a mean age of 27.5 years ( range 15 to 60 years ) , underwent appendectomy and were studied . Thirty patients received 1 gm intravenous metronidazole preoperatively and five intravenous doses of 500 mg metronidazole postoperatively . Forty-two patients received placebo only . Cultures of the appendiceal stump grew aerobic cultures in 45 ( 62 % ) and anaerobic organisms in 29 ( 40 % ) : Escherichia coli and Bacteroides fragilis , respectively . Six of the 72 patients ( 8.2 % ) developed postoperative wound infections : four of 42 ( 9.5 % ) who received placebo and two of 30 ( 6.6 % ) who received metronidazole ( P = 0.54 by Fisher exact test ) . No toxicity from metronidazole  was observed . The postoperative wound infection rate is insufficient to demonstrate the efficacy of metronidazole for prophylaxis in nonperforated acute appendicitis , although there appears to be a tendency of to assume its efficacy in this regard A prospect i ve , r and omized , clinical study was done to evaluate the place of  prophylactic antibiotics  in uncomplicated childhood appendicitis . One hundred patients with uncomplicated appendicitis were r and omly assigned to one of four groups , each consisting of 25 cases . Group 1 patients did not receive prophylactic antibiotic . Group 2 , group 3 , and group 4 patients received ornidazole , penicillin plus tobramycin , and piperacillin , respectively . The use of prophylactic antibiotics did not yield better results than the use of placebos . The rarity of infectious complications after uncomplicated appendicectomy may be unique for children . Although the need for antibiotic prophylaxis is well documented in adults , the rarity of infectious complications makes it highly question able in the treatment of uncomplicated appendicitis in children The role of prophylactic antibiotics is well established for contaminated wounds , but the use of antiseptic wound wicks is controversial . The aim of this work was to study the potential use of wound wicks to reduce the rate of infection following appendectomy . This prospect i ve r and omized controlled clinical trial was conducted at a university hospital in the department of surgery . The subjects were patients undergoing appendectomy for definite acute appendicitis . They were r and omized by computer to primary subcuticular wound closure or use of an antiseptic wound wick . For the latter , ribbon gauze soaked in povidone-iodine was placed between interrupted nylon skin sutures . Wicks were soaked daily and removed on the fourth postoperative day . All patients received antibiotic prophylaxis . They were review ed while in hospital and 4 weeks following operation for evidence of wound infection . The main outcome measures were wound infection , wound discomfort , and cosmetic result . The overall wound infection rate was 8.6 % ( 15/174 ) . In patients with wound wicks it was 11.6 % ( 10/86 ) compared to 5.6 % ( 5/88 ) in those whose wounds were closed by subcuticular sutures ( p = NS ) . We concluded that the use of wound wicks was not associated with decreased wound infection rates following appendectomy . Subcuticular closure is therefore appropriate in view of its greater convenience and safety . RésuméDans les plaies contaminées , le rôle de l’antibioprophylaxie est bien établi mais l’utilisation des pansements antiseptiques reste controversé . Le but de cette étude a été d’évaluer le potentiel d’utilisation de mèches antiseptiques dans la réduction du taux d’infection après appendicectomie . Cette étude , contrôlée par r and omisation , provenant d’un service de chirurgie universitaire , comprend des patients opérés d’appendicectomie pour appendicite aiguë . Les patients ont été r and omisés selon une méthode informatique pour recevoir soit une fermeture sous-cutanée primitive soit l’utilisation d’un pansement antiseptique . Dans ce dernier cas , la plaie a été traitée par un ruban de gaze trempé dans une solution de polividone iodé placé entre des sutures cutanées à points séparés . Les mèches ont été imbibées tous les jours et enlevées au quatrième jour . Tous les patients ont eu une antibioprophylaxie . Tous les patients ont été revus à l’hôpital et quatre semaines après leur sortie . Les critères de jugement ont été : l’infection de la plaie , une gène au niveau de la plaie et l’aspect esthétique . Le taux d’infection global a été de 8.6 % ( 15/174 ) . Chez les patients avec des pansements , ce taux a été de 11.6 % ( 10/86 ) comparé à 5.6 % ( 5/88 ) chez les patients do nt la plaie a été fermée par sutures sous-cutanées ( p = NS ) . L’utilisation de mèches ne diminue pas le taux d’infection de la plaie après apfrendfcectomie . La fermeture sous-cutanée est donc appropriée en vue de son applicabilité et sécurité . ResumenEn heridas contaminadas el papel de la antibioticoprofilaxis está bien definido , pero la introducción dentro de la herida de tiras antisépticas sigue est and o controvertida . El objetivo de este estudio fue valorar la posible utilidad de la colocación de tiras asépticas en la reducción de las infecciones de las heridas operatorias tras apendicectomía . En un departamento quirúrgico de un Hospital Universitario se realizó este estudio prospect ivo r and omizado y controlado . En él se incluyeron todos aquellos pacientes apendicectomizados por padecer una apendicitis aguda verdadera . Los pacientes se r and omizaron mediante ordenador para que en unos , se suturase primariamente el tejido celular subcutáneo y en otro , se empleasen tiras antisépticas . Las tiras de gasa empapadas en povidona yodada se introdujeron entre los puntos entrecortados de piel . Las tiras se empapaban diariamente con povidona yodada y se retiraron al 4 ° día del postoperatorio . Todos los pacientes recibieron antibioticoprofilaxis . Fueron curados y revisados durante su estancia hospitalaria y a las 4 semanas de la operación con objeto de valorar la existencia o no de infección de la herida operatoria . Se evaluaron : la infección de la herida , molestias a su nivel y result ados cosméticos . La incidencia global de infección de la herida operatoria fue del 8.6 % ( 15/174 ) . En pacientes tratados con tiras asépticas alcanzó el 11.6 % ( 10/86 ) mientras que las heridas en las que se suturó el tejido celular subcutáneo el porcentaje de infección fue del 5.6 % ( 15/88 ) p = NS . Tras apendicectomía , la infección de la herida operatoria no disminuyó con un tratamiento de tiras asépticas . La sutura del tejido celular subcutáneo parece ser más conveniente y segura A prospect i ve , r and omized , double-blind clinical study was performed to determine the efficacy of perioperative systemic antibiotics in preventing infection after appendectomy for acute nonperforating appendicitis . One hundred three patients received three doses of either placebo ( saline , n = 52 ) or cefoxitin sodium ( n = 51 ) . The two groups were similar with regard to age distribution , sex ratio , duration of operation , pathologic condition of appendix , and hospital stay . Postoperative wound infections were detected in 9.6 % of the placebo-treated patients , whereas none occurred in the cefoxitin group . All but one infection appeared after discharge . Cost analysis identified a net savings of $ 84 per patient with the use of prophylactic antibiotics . Septic morbidity after appendectomy for nonperforating appendicitis is significantly reduced by systemic antibiotics , and brief administration of a single broad-spectrum agent ( cefoxitin ) is effective prophylaxis A prospect i ve , r and omized , double-blind clinical study was performed to determine the efficacy of short-term ( 24 hr ) perioperative antibiotics in preventing septic complications after emergency appendectomy for nonperforated appendicitis . The patients were stratified into three clinical arms : Group I ( placebo , n = 45 ) , Group II ( cefam and ole , n = 46 ) and Group III ( cefam and ole plus carbenicillin , n = 45 ) . The three groups of patients were similar in regard to age , sex , duration of operation and pathologic classification of the appendix . The overall incidence of infection in the study was 5.1 % . The infection rates in Groups II ( 2.2 % ) and III ( 0 % ) were significantly lower than Group I ( placebo ) ( 13.3 % ) , ( p ≤ 0.05 ) . No difference was observed between cefam and ole alone and cefam and ole plus carbenicillin . Average postoperative hospital days per patient for each group was : Group IAC3.8 days ; Group IIAC2.9 days ; Group IIIAC3.1 days . Cost analysis of hospitalization including cost of prophylactic antibiotics revealed a $ 247.99 per patient saving for Group II versus Group I and $ 95.53 for Group III versus Group I. Systemic prophylactic antibiotics can successfully reduce septic complications after appendectomy for non-perforated appendicitis , and a single drug ( cefam and ole ) directed at the facultative pathogens is as effective as double drug therapy , which includes specific anaerobic In a prospect i ve , block-r and omized , multicenter study , the safety and efficacy of cefoxitin in preoperative prophylaxis were studied . 1735 patients undergoing appendectomy were evaluable , and half of these patients received 2 g of cefoxitin before undergoing operation . The patients were divided into three groups : patients with a normal appendix , patients with an acutely inflamed appendix , and patients with a gangrenous appendix . The study showed for each group a significant reduction of the incidence of wound infection in patients receiving prophylaxis . However , intra-abdominal abscess formation was not influenced by preoperative antibiotic prophylaxis . Consequently , routine preoperative prophylaxis is recommended before appendectomy A comparison of single-agent antimicrobial therapy in the treatment of patients with perforated or gangrenous appendicitis and peritonitis was performed in a double-blind , r and omized , prospect i ve trial . Pathologic documentation of advanced appendicitis and positive intraoperative specimen cultures were required for inclusion in the study . Ceftizoxime ( 2 gm every 12 hours ) and cefoxitin ( 2 gm every six hours ) were compared . There were no significant differences between the treatment groups . Ninety-seven percent of patients treated with ceftizoxime and 89 % of those treated with cefoxitin were cured or improved ; there was no mortality in either group . By the use of optimal sampling , transport , and culture techniques , the number and diversity of bacteria recovered from these patients with advanced appendicitis were found to be much larger than previously suspected . Peritoneal fluid , abscess contents ( if present ) , and appendiceal tissue ( obtained so as to exclude the lumen ) were cultured from all patients . An average number of 3.1 aerobic or facultative bacteria species and 8.5 anaerobic species were isolated from each specimen . Twenty-eight different genera and more than 55 species were encountered , including a previously undescribed fastidious gram-negative anaerobic bacillus . Bacteroides fragilis group and Escherichia coli were isolated from almost all specimens , and within the B fragilis group , eight species were represented . The recovery of such an unexpectedly large and diverse flora may be the reason for the therapeutic failures in these patients . We conclude that single-agent antimicrobial therapy in patients with advanced appendicitis and peritonitis is both safe and effective , and , with ceftizoxime , can be accomplished by a twice-daily dosing regimen The 588 consecutive patients who were operated on on suspicion of appendicitis were r and omized into three groups : the control group ( no prophylaxis ) ; the single-dose group ( preoperatively 500 mg of tinidazole intravenously ) ; and the 3-day group ( in addition to the former , a 3-day tinidazole treatment ) . To discover any postoperative infectious complications , the patients ' follow-up study was extended for at least 1 month . Such complications emerged in 12 % of the patients in the control group , in 7 % of those in the single-dose group , and in 5 % of those in the 3-day group . A statistically significant difference in the incidence of infectious complications was established between the control group and the prophylaxis groups . The 3-day tinidazole treatment , as compared with the single-dose prophylaxis , did not further improve the outcome . On the basis of these results the authors recommend that all patients subjected to an appendicectomy be given an intravenous tinidazole prophylaxis A r and omized double-blind trial was carried out in 405 patients undergoing appendicectomy to assess the prophylactic effect of metronidazole in postoperative infection . 200 patients received metronidazole and 206 received placebo .  Preoperatively all patients were given an intravenous infusion of metronidazole or placebo . In patients with a perforated appendix postoperative medication was continued with suppositories containing either metronidazole or a placebo plus additional chemotherapy with penicillin and streptomycin . The infection rate in patients with a non-perforated appendix was 8 % in the placebo group and 1 % among those receiving metronidazole . In patients with a perforated appendix , the corresponding figures were 45 % and 0 % . These differences are statistically significant . B. fragilis and E. coli were isolated from the majority of the postoperative infections;. most often in a mixed culture . Both intravenous and rectal administration of metronidazole gave adequate blood levels . No side effects were encountered A prospect i ve r and omized trial comparing prophylaxis with a single dose of cefam and ole given intravenously and preincisionally with no antibiotics in patients who underwent elective and emergency operations upon the gastrointestinal tract has shown a significant reduction in the frequency of wound infections in patients receiving preincisional antibiotics over both control and intravenous groups . Fewer postoperative infections of the chest occurred in patients receiving antibiotics by either route , with hospital stay also being significantly reduced for patients who received prophylactic antibiotics  before emergency operations . Preincisional cefam and ole is effective in reducing postoperative sepsis after operations upon the gastrointestinal tract The proper duration of postoperative intravenous ( IV ) antibiotics in patients suffering complicated ( perforated or gangrenous ) appendicitis is debatable . Some advocate a set minimum number of IV antibiotic days whereas others discontinue IV antibiotics depending on the patient 's clinical course regardless of the length of therapy . Our objective was to determine whether there are differences in morbidity and re source utilization between the two treatment method ologies . Ninety-four patients with intraoperative findings of complicated appendicitis were included . In all patients IV antibiotics were discontinued on the basis of clinical factors . However , Group 1 patients were given a minimum 5-day IV antibiotic course whereas Group 2 patients had no minimum IV antibiotic requirement . Group 1 patients received more  IV antibiotics  than Group 2 patients did ( 5.9 vs 4.3 days ; P = 0.014 ) . Infectious complications were not statistically different between the two groups ( 13.0 % in Group 1 and 12.5 % in Group 2 ) . Average hospital stay was also not statistically different between the two groups . The data suggest that a protocol with no minimum IV antibiotic requirement in patients with complicated appendicitis does not increase morbidity . Furthermore , the protocol arm with no minimum IV antibiotic requirement led to less IV antibiotic use but did not significantly decrease hospital stay A double blind , r and omized , controlled trial was carried out at two hospitals to try the effect of metronidazole , which is effective against most anaerobes , and cefazolin , which is effective against many aerobic organisms , singly and in combination , on the incidence of wound sepsis following appendicectomy . Patients were placed at r and om into one of four groups ; to receive metronidazole and placebo , cefazolin and placebo , metronidazole and cefazolin , or double placebo .  Patients with generalized peritonitis were excluded for ethical reasons . Treatment was started before operation and continued eight-hourly for twenty-four hours . All patients in the trial were followed up at about two weeks after discharge from hospital and their wounds inspected . Two hundred and seventy-one patients were assessed .  Sepsis rates at the two hospitals were similar . On the untreated controls , 30 % discharged pus from their wounds , and in the groups receiving one drug only , about 20 % . In those receiving both drugs the infection rate was 3 % , a highly significant difference from that in the other three groups Acute appendicitis continues as a medical challenge with newer approaches failing to improve diagnostic accuracy . The role of antibiotics in acute nonperforative appendicitis ( NPA ) remains unclear . In 175 patients studied at two hospitals , preoperative guidelines were used to exclude perforative appendicitis . Nevertheless , 14 % of patients were found to have this condition . Surgeon 's reports significantly underestimated the diagnosis when compared with the pathologists ' reports . Antibiotic prophylaxis in 122 patients with NPA was studied prospect ively comparing ceftizoxime ( CTZ ) , cefam and ole ( CFM ) , and placebo ( PLA ) . Ceftizoxime decreased the infection rate compared with PLA ( 0 vs. 8 ; P less than .01 ) . Use of antibiotics ( CTZ or CFM ) result ed in decreased infections when compared with PLA ( 3 vs. 8 ; P less than .01 ) and fewer days of hospitalization ( 3.8 vs. 5.4 d , P less than .005 ) . Analysis of infection risk factors showed no correlations except for failure to administer antibiotics and the finding of a gangrenous appendix . Operative culture results had no predictive value for either infection or pathogen identification . It is recommended that all patients undergoing surgery for NPA be given 1 d of antibiotic prophylaxis In a prospect i ve r and omized double blind study , prophylactic cefam and ol therapy was compared to placebos before appendectomy . 25 of 220 patients had to be excluded . The overall infection rate was reduced from 13,1 % ( 1977/78 ) to 7,6 % ( 1979/80 ) . The infection rate differed in both groups ( antibiotic and placebo ) only for perforated appendices significantly . If there was a wound infection , the hospital stay of the treatment group was significantly reduced to the placebo group ( p less than 0,0005 ) . Predisposing factors for wound infection are  leucocytosis greater than 12 000 , anamnesis greater than 24 hours , operation time greater than 45 minutes The effect of a preoperative single intravenous dose of metronidazole was studied in a prospect i ve trial of 203 patients . 17.5 % of the patients in the control group developed a wound infection compared with 3.4 % of those receiving metronidazole ( p less than 0.001 ) . The average length of hospitalization and convalescence was significantly reduced in the metronidazole group . The use of metronidazole in prevention of wound infection is recommended When given in conventional daily dosage , rifampicin is highly effective but very expensive , costing well over £ 200 a year for one patient . This makes the use of daily rifampicin regimens unrealistic in nearly all the developing countries and indeed in many technically advanced countries too . If an intermittent regimen containing a smaller total weekly dosage of rifampicin which is both therapeutically effective and of low toxicity could be found the applicability of this very valuable drug would be much increased . It would indeed be a great pity if the report of Dr. Poole and others were to be interpreted as discouraging further investigation along these lines . In the final analysis the aim must be to evaluate rifampicin-containing regimens in terms of efficacy , safety , convenience , cost and applicability , in comparison with the alternative regimens available for the treatment of the same type of disease , in the same population .-We are , etc . Abstract The efficacy of intraoperative cephalothin irrigation of the peritoneal cavity was evaluated in ninety-four operative procedures on ninety-two patients . The study was prospect i ve and double blind and the patients were selected for the cephalothin or control group on a r and om basis . Evaluation of the two groups in regard to wound infections , failure to control intraperitoneal sepsis as indicated by intra-abdominal abscess or continuing peritonitis , and total number of deaths failed to reveal any significant difference between the two groups . Thus , copious cephalothin irrigation appears to be no better or worse than copious saline irrigation in the patient with peritonitis A single intravenous dose of tobramycin and lincomycin , given at the start of gastrointestinal operations , significantly reduced the incidence of postoperative wound infection from 34 % to 5 % . The occurrence of both anaerobic and aerobic bacteria was reduced . Therapeutic concentrations of the antibiotics were maintained throughout the operative period in most cases . No toxic effects of the antibiotics were detected , no anaesthetic complication occurred , and resistant strains of bacteria normally sensitive to the antibiotics were not isolated from wounds The effects of intrarectal metronidazole and intraincisional povidone iodine on  sepsis after emergency appendicectomy were compared in a double-blind r and omised controlled trial in 496 patients .  Wound sepsis occurred in 12.3 % of metronidazole-treated patients compared with 24 % in the povidone-iodine group and 23.5 % in an untreated control group . The metronidazole-treated patients left hospital approximately 2 days earlier than patients in the other two groups . They returned to work sooner and receiver fewer visits from the district nursing service . A short six-dose course of metronidazole significantly reduces the wound-infection rate in patients over the age of 12 undergoing emergency appendicectomy . If the clinical and economic benefits of metronidazole shown by this study are confirmed , the drug should be considered for routine use in emergency appendicectomy 131 patients from 158 appendicectomies were r and omly divided before the operation into two groups : a single intravenous dose of metronidazole , and a physiological saline placebo group . The overall infection rate was 8.4 % . In the non-perforated cases the infection rates were 3.4 % in the metronidazole and 7.9 % in the placebo group . In cases with perforated appendix the infection rate was 40 % . There was no statistically significant difference in the infection rates between the groups . Our results give no clear indication of the benefit of metronidazole prophylaxis and we propose , therefore , to concentrate on the technical aspects of appendicectomy in infection prophylaxis In a series of 349 operations a single dose of 500 mg . of ampicillin was given immediately preoperatively to 164 patients selected at r and om . There was no significant reduction in the wound‐infection rate in cases given ampicillin compared with the controls Abstract From March 1 , 1966 through March 31 , 1967 , 525 patients on the General Surgery Service of Brooke General Hospital underwent abdominal surgery during which the gastrointestinal or the biliary tracts were open . In three ( 1.5 per cent ) of 189 patients who received prophylactically a combination of penicillin G , chloramphenicol , and methicillin before , during , and immediately after operation wound infections developed , whereas wound infections occurred in thirty-seven of 336 control patients . The difference in incidence of infection between these two groups of patients is highly significant ( p Specific groups of patients in whom the incidence of wound infections apparently was reduced significantly by prophylactic administration of antibiotics included those who underwent cholecystectomy , emergency gastric surgery for bleeding , elective gastric surgery , and emergency colostomies . In view of the high degree of statistical significance in the difference in incidence of wound infection in the totals of treated and control patients , the lack of statistically significant difference in incidence of wound infections between treated and control subgroups of patients undergoing other abdominal operations probably can be attributed to the small number of patients in these groups OBJECTIVE To assess whether antibiotic treatment with cefuroxime and tinidazole started during the operation was as effective as treatment started before operation in patients with gangrenous non-perforated appendicitis . DESIGN Prospect i ve r and omised study . SETTING University hospital , Sweden . SUBJECTS 114 patients with gangrenous , non-perforated appendicitis who had had antibiotics started before operation and 120 whose treatment was started during operation out of a total of 575 who presented with a presumptive diagnosis of appendicitis . MAIN OUTCOME MEASURES Morbidity and mortality . RESULTS There were no deaths , and the rates of infective complications were 1/114 ( 0.9 % ) and 3/120 ( 3 % ) , respectively . The median hospital stay was four days in both groups . CONCLUSION Antibiotic treatment started during the operation is not significantly worse at preventing infective complications in non-perforated , gangrenous appendicitis than treatment started before the operation The effect of topical ampicillin on the rate of wound infection after emergency appendicectomy  was studied in a prospect i ve controlled trial of 200 patients . Sixteen per cent of patients in the control group developed a wound injection compared with 3 per cent of those receiving ampicillin powder in the wound ( P<0.01 ) . When patients with peritonitis were considered , 64 per cent of the 14 patients in the control group developed a wound infection compared with 13 per cent of the 15 patients in the ampicillin group A series of 102 patients with presumptive acute appendicitis entered a prospect i ve , r and omized , clinical trial of intrarectal metronidazole given over a 48‐h period commencing before surgery . Adequate levels of circulating metronidazole were achieved . A significant reduction in the incidence of anaerobic wound infection was observed in the treated group ( P < 0.02 ) . The convenience and short duration of the prophylactic regimen allowed early discharge from hospital . No untoward effects were observed A double-blind , r and omized controlled trial was carried out in University Hospital , Kuala Lumpur to study the effect of metronidazole and cotrimoxazole on the incidence of wound infection following appendicectomy from November 1978 to January 1980 . Patients were allocated at r and om into one of four groups : cotrimoxazole injection and placebo suppository , metronidazole suppository and cotrimoxazole injection , metronidazole suppository and placebo injection or placebo suppository and placebo injection . Treatment was started 30 min before operation and continued for 72h . All patients were followed up for 2 weeks and thereafter for one month . A total of 283 patients was finally accepted into the study .  Sepsis rates were found to be 27 % for the untreated group , 9 % for the group receiving metronidazole only , 8 % for the group receiving cotrimoxazole injection only and 2.7 % for the group receiving both drugs . The study showed that a combination of metronidazole and cotrimoxazole is a regime highly effective for prophylaxis against wound infection following appendicectomy Abstract All 253 appendicectomies done at a district general hospital over a five- month period were included in a controlled trial of wound spraying ( povidone iodine or polyantibiotic aerosols ) as a prophylactic measure against postoperative wound infection . A statistically significant reduction in the rate of infection was achieved . The routine use of a povidone iodine dry powder aerosol spray ( ' Disadine ' D.P. ) was justified because it reduced the incidence of wound infection in all degrees of appendicular inflammation without the risk of inducing the development of antibiotic-resistant bacterial strains The frequency of non-clostridial anaerobic infection was studied in 95 patients who had undergone acute appendicectomy : 49 received prophylactic metronidazole and 46 received placebo .  Anaerobic infection did not develop in any of the metronidazole-treated patients , but infections did develop in nine ( 19 % ) of the 46 controls . Metronidazole is conveniently administered by suppository to patients who can not take oral drugs . Five patients with intra-abdominal infections caused by non-clostridial anaerobes were successfully treated with metronidazole The value of extraperitoneal wound drainage and a 3‐day course of prophylactic systemic cephaloridine used both separately and together have been assessed in a prospect i ve controlled r and omized trial involving 246 patients undergoing appendicectomy at the Leicester Royal Infirmary .  Extraperitoneal wound drainage was shown to reduce significantly the incidence of post‐operative wound infection in patients with a gangrenous or perforated appendix ( P<0·025 ) . Prophylactic cephaloridine significantly reduced the overall incidence of wound infection ( P<0·02 ) and was also effective when the appendix was gangrenous or perforated ( P<0·01 ) . A highly significant reduction in wound infection was achieved when the appendix was gangrenous or perforated by the addition of wound drainage to the antibiotic regimen ( P<0·001 ) Prophylactic metronidazole was compared with no treatment in a r and omly allocated study of patients undergoing appendicectomy . A 1‐g suppository of metronidazole was given with the premedication and 200 mg t.d.s . orally for 7 days thereafter The prophylactic use of a single dose of lincomycin in 100 patients undergoing appendicectomy  reduced the incidence of postoperative wound injection from 17 to 6 per cent compared with a similar group of control patients . There was no correlation with the histological findings in the appendix , but patients with perforated appendicitis were excluded from the study . Bacteriological examination of the appendix area before surgery showed that Bacteroides fragilis and Escherichia coli were the organisms most frequently isolated . The majority of wound infections were due to B. fragilis , either alone or in association with aerobic organisms , but infection due to E. coli and Staphylococcus aureus also occurred A prospect i ve placebo controlled r and omized trial was carried out in 104 patients with a presumptive diagnosis of acute appendicitis . A single dose of 1 g of metronidazole was given intra‐rectally 1 h preoperatively . There were 16 wound infections , 15 ( out of 50 ) in the placebo group , 1 ( out of 54 ) in the metronidazole group . This study supports the already accepted value of metronidazole but suggests that a single intra‐rectal dose regimen is adequate for prophylaxis In the course of two consecutive , double-blind and prospect i ve studies , the authors evaluated the prophylactic effect of a single peroperative intravenous dose of gentamicin  ( this study included 166 patients ) or the combination gentamicin and clindamycin  ( this study included 127 patients ) , on the  wound infection rate following interventions involving the incision of an abdominal hollow viscus . Antibiotic prophylaxis lowered the post-operative wound sepsis rate , especially following clinical ly contaminated interventions , but this reduction did not reach statistical significance . It is concluded that a single peroperative parenteral dose of antibiotics does not constitute an entirely satisfactory means of wound infection prophylaxis in digestive surgery In an open prospect i ve r and omized study of appendicectomy , single-dose ( 1 g ) intravenous metronidazole prophylaxis ( and continued metronidazole plus nalidixic acid in perforated appendices ) result ed in a lower overall post-operative infection rate ( 1.4 % ) than no prophylaxis and doxycycline therapy in the case of perforation ( 16 % , p less than 0.025 ) . In patients with an unperforated appendix  no infections occurred after single-dose metronidazole prophylaxis as opposed to 8.2 % infections in untreated controls ( p less than 0.025 ) A prospect i ve study was carried out to evaluate the effect of a strictly st and ardized , short-term prophylactic treatment with cephalothin ( Keflin ) on the incidence of postoperative wound infections in gastrointestinal surgery . Achieved levels of cephalothin activity in serum and interstitial water were studied , and the sensitivity of isolated bacteria at the end of operation and from septic wounds was defined . Patients were divided at r and om into treatment and control groups . The treatment group received 2 g cephalothin at the induction of anesthesia and another 2 g , 5 and 10 hours after the primary infusion . The control group remained untreated . The rapid infusion of 2 g cephalothin result ed in high initial serum levels , which declined rapidly . Equilibration between intra and extravascular compartments occurred about 60 - 80 minutes after start of infusion . At that time the infused dose result ed in a cephalothin level of about 30 mug/ml in ECV and plasma , or about 30 % of the initial concentration . Despite the prophylactic infusion of cephalothin , the frequency of wound infection in treated patients was the same as in the controls . Subdivision of the material according to type of surgery performed did not reveal any difference between untreated patients and controls . No shift towards cephalothin-resistant strains was observed in isolates from septic wounds in the treatment group
target: The outcome measures of the studies were : Wound infection , intra abdominal abscess , length of stay in hospital , and mortality .
  The overall result is that the use of antibiotics is superior to placebo for preventing wound infection and intraabdominal abscess , with no apparent difference in the nature of the removed appendix .
  Studies exclusively on children and studies examining topical application reported results in favour to the above , although the results were not significant .
  Antibiotic prophylaxis is effective in the prevention of postoperative complications in appendectomised patients , whether the administration is given pre- , peri- or post-operatively , and could be considered for routine in emergency appendectomies
background: BACKGROUND Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention .
  The cause of appendicitis is unclear and the mechanism of pathogenesis continues to be debated .
  Despite improved asepsis and surgical techniques , postoperative complications , such as wound infection and intraabdominal abscess , still account for a significant morbidity .
  Several studies implicate that postoperative infections are reduced by administration of antimicrobial regimes .
  OBJECTIVES This review evaluated the use of antibiotics compared to placebo or no treatment in patients undergoing appendectomy .
  Will these patients benefit from antimicrobial prophylaxis ?