title: Is abdominal cavity culture of any value in appendicitis? Perioperative prophylaxis with sulbactam and ampicillin compared with metronidazole and cefotaxime in the prevention of wound infection in children undergoing appendectomy. [Antibiotic treatment of perforated appendicitis in childhood--a prospective study]. Antibiotic management of complicated appendicitis. Acute appendicitis in children. Perforated appendix and antibiotics. Perforated appendicitis: prospective outcome analysis for 150 children. [Antibiotic therapy of perforated appendicitis in children: comparison between the amoxicillin-clavulanic acid and the benzylpenicillin-netilmicin-metronidazole combinations]. Discharge planning for children with perforated appendicitis. Adjunctive antimicrobial therapy for complicated appendicitis: Bacterial overkill by combination therapy One-drug versus two-drug antibiotic therapy in pediatric perforated appendicitis: a prospective randomized study. Subcuticular Skin Closure as a Standard Approach to Emergency Appendectomy in Children: Prospective Clinical Trial Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis. A randomized comparative study of sulbactam plus ampicillin vs. metronidazole plus cefotaxime in the management of acute appendicitis in children. Imipenem‐cilastatin vs. tobramycin and metronidazole for appendicitis‐related infections Management of peritonitis in perforated appendicitis in children. Early appendectomy for perforated appendicitis in children should not be abandoned. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. Comparative trial of four antibiotic combinations for perforated appendicitis in children. A preliminary report of ticarcillin and clavulanate versus triple antibiotic therapy in children with ruptured appendicitis. Ceftazidime/metronidazole versus netilmicin/metronidazole in the treatment of perforated appendicitis in children.
abstract: BACKGROUND Intraperitoneal culturing during appendectomy is a routine procedure . Significant decrease in the mortality and dramatic improvement in the morbidity were achieved by using antibiotics perioperatively . The value of intraoperative abdominal cavity culture was assessed in our study . METHODS A total of 499 patients formed two groups , those with acute nonperforated appendicitis ( group A ) and those with perforated appendicitis ( group B ) . Intraoperative abdominal cavity culture were taken r and omly in both groups . The perioperative morbidity , the validity , and the impact of positive culture on the antibiotic treatment were examined in both groups . RESULTS Clinical diagnosed perforation was confirmed histologically in 176 patients ( 98.3 % accuracy ) . Intraperitoneal cultures were obtained in 30.1 % of the patients in group A and in 67.1 % of group B. The majority of the patients in group A were treated preoperatively and postoperatively by a single antibiotic agent whereas 58.0 % of the patients in group B were started on triple-agent antibiotics for significantly longer periods ( 22.4 + /- 9.4 versus 5.7 + /- 7.4 doses , respectively ; P < 0.0001 ) . No significant difference was found in both groups in the postoperative complication rate ( wound infection , intra-abdominal abscess and small bowel obstruction ) whether intra-abdominal culture was obtained or not ( 5.9 % versus 4.7 % in group A and 21.2 % versus 21.9 % in group B ; P > 0.05 ) . CONCLUSION Traditional intraoperative abdominal cavity culture can be ab and oned . In perforated appendicitis , colonic flora can be predicted , and antibiotic therapy should begun without any abdominal cavity culture results . This practical approach will save money and reduce laboratory work without affecting the patient 's morbidity Sulbactam is a beta-lactamase inhibitor , which when administered with ampicillin , increases the latter agents antibacterial activity against beta-lactamase producing organisms . One hundred children between the ages of 5 and 14 undergoing emergency appendectomy were entered into a prospect i ve r and omized trial comparing sulbactam and ampicillin ( SA ) with metronidazole and cefotaxime ( MC ) as prophylaxis against postoperative wound infection .  Patients in whom the appendix was perforated or gangrenous received a 72-hour course of antibiotics , others received a single dose only . The overall wound infection rate was 8 % ( 14 % in patients with perforation or gangrene and 4 % in those without ) . There was no difference in infection rate between the two antibiotic groups ; there were three wound infections and one subphrenic abscess in patients receiving SA and four wound infections in patients receiving MC . SA , therefore , appears to be a suitable antibiotic combination for use as prophylaxis in appendicitis in children A prospect i ve r and omised study ( I ) was carried out on 130 children undergoing laparotomy for perforated appendicitis . The present study evaluates the therapeutic effectiveness of different antibiotic regimens in modifying the rate of post-operative complications ( intraabdominal abscess , ileus , wound infiltration or abscess ) . During the first year of this study two treatment groups were used . Group A consisted of 29 children treated with Sulfometrol/Trimethoprim ; the rate of postoperative complications was 44.8 % . Group B consisted of 36 children treated with mezlocillin , the rate of complications being 13.8 % . However , the same treatment with mezlocillin during the second year of the prospect i ve study showed an increase of this rte to 39 % ( 28 children -- group C ) . The final group of 37 children was treated during the second year with mezlocillin and metronidazole ( group D ) . The postoperative rate of complications was 10.8 % . A retrospective analysis of further 80 children ( study II ) with perforated appendicitis treated with mezlocillin and metronidazole  showed a consistent low rate of postoperative complications at 10.2 % . In 6.8 % of children studied , an operative intervention was necessary ( four cases of ileus , four wound abscesses ) . The mean postoperative hospitalisation period decreased from 22.7 days in group A to 15.2 days in group D and finally to 14 days in study II . The present study shows that an effective and persistent attenuation of the rate of postoperative complications after perforated appendicitis in children depends on an early onset of therapy and on the appropriate choice of antibiotic drugs that are effective against aerobic and anaerobic microorganisms A prospect i ve , r and omized , double-blind clinical trial was undertaken comparing gentamicin , ampicillin , and clindamycin ( GAC ) to gentamicin , ampicillin , and placebo ( GAP ) in children with complicated appendicitis . Of the 64 patients enrolled in this study , 33 were assigned to the GAC group and 31 received GAP . A single GAC patient ( 3 % ) was considered a therapeutic failure in comparison to seven children ( 23 % ) in the GAP group ( P less than 0.05 ) . Duration of fever was significantly prolonged in the GAP patients ( 4.7 + /- .8 days versus 2.9 + /- .5 days ) when compared to the clindamycin treated children ( P less than 0.05 ) . Duration of leukocytosis was 3.2 + /- .4 days for GAC patients and 4.9 + /- .9 days for those on the GAP protocol ( P = 0.08 ) . On the basis of this experience the routine use of gentamicin , ampicillin , and clindamycin is recommended for all children with complicated appendicitis A prospect i ve study was conducted on 344 children aged from 3 months to 16 years with acute appendicitis . Most children presented with typical features of acute appendicitis ( 70 % ) or peritonitis ( 28 % ) . Atypical presentation was uncommon and occurred only in seven young children , masquerading as intestinal obstruction , gastroenteritis or urinary tract infection . Prolonged delay in surgery was associated with a rise in incidence of late appendicitis ( gangrenous and perforated appendicitis ) . This rise was especially marked 37 h after onset of symptoms . The main causes of delay were inability of the parents and primary care medical practitioners to recognize the disease early . Surgeons contributed very little to the delay . High risk factors for postappendectomy sepsis were young children under 6 years old , late appendicitis , obese patients , inferior systemic antibiotic regimes and inexperienced surgeons . Young children had high postoperative sepsis mainly because of the high incidence of late appendicitis due to their inability to express their symptoms properly . They were not especially prone to postappendectomy sepsis ; they had the same degree of appendicitis compared with older children . Measures to decrease the postappendectomy morbidity are suggested 60 consecutive children operated for perforated appendicitis were treated r and omly with either penicillin and streptomycin or with clindamycin and gentamycin .  Suppurative complications occurred somewhat more often and were definitely more severe in the former group . The number of hospital days spent in the treatment of these complications were three times as great in the former than in the latter group . Bacteroides fragilis could be isolated in most of the severe infections treated without clindamycin . Two out of 28 patients treated with clindamycin presented with severe diarrhoea BACKGROUND / PURPOSE Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration , operative timing , drain utilization , and wound closure . For 2 decades at the authors ' institution , patients were treated with ampicillin , gentamicin , and clindamycin for 10 inpatient days , with drains in the abdomen , result ing in lower complication rates than most other published series . Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes . In addition , there are little prospect i ve data on clinical outcomes . The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aim ed at decreasing cost and length of stay in our protocol were instituted . METHODS The authors monitored prospect ively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period . Patients received a single antibiotic , piperacillin-tazobactam , intravenously for 10 days . They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met . Other practice s from our earlier protocol were continued , including immediate operation , placement of Penrose drains , and primary wound closure . RESULTS Of 150 patients treated on our protocol , major complications included intraabdominal abscess in 5 ( 3.3 % ) , cecal fistula in 2 ( 1.3 % ) , phlegmon in 3 ( 2.0 % ) , wound infection in 4 ( 2.7 % ) , and no small bowel obstructions requiring operation . None of these complications , nor their aggregate , were significantly more common than those reported in 373 patients treated over 11 years on the authors ' prior protocol ( chi2 , P > .05 ) . CONCLUSIONS Prospect i ve outcome analysis of our protocol shows that a single broad-spectrum antibiotic ( allowing portions of therapy to be delivered less expensively on an outpatient basis ) effectively can treat postoperative appendicitis with very few infectious complications . These outcome data provide baseline against which future protocol s can be compared . All treatment modifications aim ed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised In a multicentre trial we compared the clinical efficacy of amoxicillin/clavulanate used as a single-agent therapy with that of the three-agent combination usually prescribed in the post-operative period for appendicular peritonitis in children . Only bacteriologically documented peritoneal infections were included . Sixty-four patients were r and omly distributed between two groups : Group A ( 29 cases ) treated with amoxicillin/clavulanate , first administered iv ( 100 mg/kg/d ) , followed by conversion to the oral route ( 50 mg/kg/d ) once the patient had been afebrile for 48 hours ; Group B ( 35 cases ) first treated by the iv route with benzylpenicillin ( 100,000 IU/kg/d ) plus netilmicin ( 5 mg/kg/d ) plus metronidazole ( 30 mg/kg/d ) , followed by conversion to the oral route for metronidazole ( 30 mg/kg/d ) . In both groups , the total duration of parenteral and oral treatment was not less than 5 days . One hundred and seventy nine bacterial strains were recovered from peritoneal fluid sample s obtained during surgery ; 86 % of these were sensitive to amoxicillin/clavulanate .  Clinical efficacy , assessed on the basis of time until return to normal temperature and gut transit and duration of hospitalization , was identical in both groups , with follow-up monitoring on day 30 showing recovery in all cases . Cure was obtained without any problems of infection in 25/29 patients in group A and in 34/35 patients in group B ( non significant difference ) . Tolerance was excellent and identical in the two groups with the exception of three cases of thrombophlebitis which occurred in group B. The results of this study suggest that amoxicillin/clavulanate may be useful as single-agent therapy as a first-line curative treatment for appendicular peritonitis in children Optimal management of children with perforated appendicitis remains a controversial clinical problem . Until very recently , the criteria for hospital discharge on our surgical service included the absence of fever and leukocytosis for a period of 48 hours following completion of antimicrobial therapy , uncomplicated wound healing , a normal rectal examination , and unimpaired gastrointestinal function . With the introduction of cost-containment programs , the necessity for the period of inpatient observation following cessation of antibiotics was question ed . The records of 87 consecutive children with perforated appendicitis were analyzed prospect ively in order to determine if our discharge policies were medically sound and cost-effective . Seventy-five patients ( 86 % ) recovered uneventfully while 12 children required prolonged hospitalization for management of various postoperative complications . The 12 patients who developed complications were all identifiable early in the postoperative period because of persistent fever , leukocytosis , and elevated b and counts . Of the 75 children who recovered uneventfully , all met st and ard discharge criteria on the final day of antibiotic therapy with the exception of completing the m and atory 48-hour period of inpatient observation . These children were maintained in the hospital a total of 142 additional days following discontinuation of antibiotics . The average cost per patient day for children with perforated appendicitis during the study period was $ 506.32 , which represented unnecessary hospital charges of $ 71,897.44 . It was concluded that inpatient observation following cessation of antibiotic therapy in children who experience an uneventful recovery from perforated appendicitis is neither necessary nor cost-effective . ( ABSTRACT TRUNCATED AT 250 WORDS Although single antimicrobials with broad-spectrum aerobic and anaerobic coverage are effective in patients with appendicitis , many general surgeons continue to use multiple agents . A prospect i ve , doubleblind , r and omized trial was design ed to detect any clinical correlate of in vitro susceptibility advantage of multiple antimicrobials as adjunctive therapy for 114 patients undergoing operation for complicated appendicitis . There was clinical resolution of intraabdominal infections with no occurrence of postoperative infectious complications in 90 % ( 36 of 40 ) of the cefotetan group and 86 % ( 31 of 36 ) of the clindamycin/amikacin group ( p=0.11 ) . The number of patients who had changes in antibiotic therapy due to postoperative complications was higher in the clindamycin/amikacin group : five ( 12.5 % ) , compared to one ( 2.8 % ) in the cefotetan group ( p=0.07 ) . Although Bacteroides fragilis group organisms resistant to cefotetan were identified , none was responsible for the postoperative infections . Adverse drug events in 28 % of the cefotetan group and 26 % of the clindamycin/amikacin group consisted primarily of transient elevations of liver function tests . Monotherapy with a second-generation , broad-spectrum cephalosporin , such as cefotetan , given twice a day is an economical and effective adjunctive regimen in patients with complicated appendicitis for which operation is the definitive treatment . Aminoglycosides and other , more potent antimicrobials should be reserved for resistant organisms or nosocomial infections . RésuméBien qu'un seul antibiotique avec un large spectre couvrant les germes aérobies et anaérobies soit reconnu comme efficace dans l'appendicite , beaucoup de chirurgiens continuent d'utiliser une polyantibiothérapie . Dans un essai contrôlé en double aveugle , nous avons testé la corrélation clinique avec la sensibilité in vitro d'une association de plusieurs antibiotiques comme traitement complémentaire chez 114 patients ayant eu une appendicite compliquée . Quatre-vingt pour-cent ( 36/40 ) des patients ayant eu du céfotétan et 86 % ( 31/36 ) des patients ayant eu l'association clindamycine/amikacíne n'ont pas eu de complications infectieuses postopératoires ( p=0.11 ) . II a été nécessaire de changer les antibiotiques en raison d'une complication postopératoire plus souvent chez les patients ayant eu l'association clindamycine/amikacine  , 5 ( 12 % ) comparé à 1 ( 2 % ) dans le groupe céfotétan ( p=0.07 ) . On a identifié des organismes Bacteroides fragilis résistants au céfotétane mais aucun n'était responsable d'infection postopératoire . II y a eu des effets secondaires non désirables , essentiellement une perturbation des tests de la fonction hépatique , chez 28 % et chez 26 % des patients ayant pris respectivement du céfotétane et l'assocíation clindamycine/amikacine  , respectivement . Une monothérapie avec une céphalosporine de deuxième génération du type céfotétan , donnée deux fois par jour , est ffficace et économique dans le traitement de l'appendicite compliquée mais opéréc . Les aminosides et les autres antibiotiques plus puissants doivent être réservés pour les germes résistants ou les infections nosocomiales . ResumenAunque los antibióticos únicos de amplio espectro de cobertura aeróbica y anaeróbica son eficaces en la apendicitis , muchos cirujanos continúan utiliz and o agentes múltiples . Se diseñó un ensayo clínico prospect ivo , doble ciego y aleatorizado con el fin de correlacionar la susceptibilidad in vitro de agentes antimicrobianos múltiples como terapia adyuvante en el manejo de 114 pacientes sometidos a operación por apendicitis complicada . 90 % ( 36/40 ) de los pacientes en el Grupo de cefotetan y 86 % ( 31/36 ) en el Grupo que recibió clindamicina/amikacina tuvieron resolución clínica de sus infecciones intraabdominales sin recurrencia de complicaciones sépticas postoperatorias ( P=0.11 ) . El número de pacientes que tuvieron cambio en la terapia antibiótica por complicaciones postoperatorias fue más alto en el Grupo clindamicina/amikacina , 5 ( 12 % ) comparados con 1 ( 2 % ) en el Grupo cefotetan ( P=0.07 ) . Aunque se identifícaron microorganismos del Grupo de los Bacteroides fragilis resistentes a cefotetan , ninguno fue responsable de infecciones postoperatorias . Se presentaron reacciones farmacológicas adversas en 28 % del Grupo cefotetan y en 26 % del Grupo clindamicina/amikacina , las cuales consistieron primordialmente en elevaciones pasajeras de los valores de las pruebas de función hepática . La monoterapia con una cefalosporina de amplio espectro de segunda generación , tal como el cefotetan , administrado en dos dosis diarias constituye un régimen económico y eficaz en la apendicitis complicada en la cual la cirugía representa el tratamiento definitivo . Los aminoglucósidos y otros agentes antimicrobianos más potentes deben ser reservados para el tratamiento de infecciones nosocomiales por microorganismos resistentes A prospect i ve r and omized study was undertaken to compare the use of the combination of gentamicin and clindamycin with single agent , cefoxitin , in the treatment of perforated appendicitis in the pediatric patient . In a 3-year period from 1986 to 1989 , 56 patients with perforated appendicitis were r and omized . Twenty-nine patients received cefoxitin , and 27 patients received gentamicin and clindamycin . Antibiotics were started before operation and continued for a minimum of 6 days after operation . Skin and subcutaneous tissues were left open at surgery and closed secondarily after day 3 , if they appeared to be clean . Wounds were considered infected if they developed increased purulence with positive wound cultures . Age range was similar in both groups , with a mean of 9 years ( range , 1 to 17 years ) ; 28 were boys and 28 were girls . No changes in antibiotics were required for reasons of susceptibility . No adverse drug reactions occurred in either group . The most common organisms were Escherichia coli in 35 cases ( 62 % ) and Bacteroides species in 26 cases ( 46 % ) . No difference was noted in infection complications in the two groups nor in length of hospital stay . Therefore , no difference is evident in the use of cefoxitin versus gentamicin and clindamycin in the treatment of perforated appendicitis in terms of disease or drug-related complications Abstract . We evaluated the morbidity associated with primary closure by interrupted subcuticular absorbable sutures  following emergency appendectomy .  In a prospect i ve clinical trial over a 12-month period , 216 children who underwent emergency appendectomy had skin closure using subcuticular interrupted absorbable polyglactin 4 - 0 sutures . Preoperative prophylactic antibiotics consisting of metronidazole alone or in combination with gentamicin were used in patients with suspected phlegmonous appendicitis ; a combination of metronidazole , gentamicin , and ampicillin was used when perforation of the appendix was suspected . Postoperatively , in patients with phlegmonous appendicitis  metronidazole was given for 24 hours , whereas in those with peritonitis the triple antibiotics were continued for 7 to 10 days . All patients were assessed for complications result ing from the technique of wound closure . No intraabdominal abscesses or serious complications were recorded . The overall incidence of wound infection was 1.8 % . Among children with a perforated appendix the rate of superficial wound infection was 5.7 % . There was no difference in the rate of wound infection between patients who received metronidazole alone or metronidazole plus gentamicin preoperatively . All the patients and their families were satisfied with the cosmetic results and with the fact that removal of skin sutures was unnecessary . We conclude that the use of prophylactic antibiotics permits st and ard skin closure by interrupted absorbable subcuticular suture BACKGROUND Children with a perforated or gangrenous appendix become clinical ly stable after medical and /or surgical therapy but often remain in the hospital solely to complete parenteral antibiotic therapy . This prospect i ve study investigates the outcomes when children who meet specified criteria are discharged to complete parenteral antibiotic therapy at home . METHODS Children age 1 to 17 years with appendicitis complicated by generalized peritonitis or intraabdominal abscess were eligible to participate . Subjects whose fever was decreasing , who were able to tolerate oral liquids and for whom further parenteral antibiotic therapy was deemed necessary were discharged from the hospital to receive outpatient parenteral antiinfective therapy ( OPAT ) with meropenem . Therapy was administered by a family member and supervised by home care nurses . Study personnel visited the home daily to collect data on adverse events , compliance and re source utilization . Pa tients served as their own controls in models of reduced hospitalization and net cost savings . RESULTS Discharged on average on the fourth postoperative day , 87 children received 4.5 + /- 2.1 days of OPAT . Six ( 7 % ) children were subsequently readmitted for complications including bowel obstruction ( 4 children ) , intraabdominal abscess ( 1 child ) and pleural effusion ( 1 child ) . Another child developed a viral syndrome during OPAT . All other patients recovered uneventfully . Six ( 7 % ) children discontinued meropenem prematurely because of rash ( 4 patients ) or diarrhea ( 2 patients ) . According to models in which each day of OPAT replaced a day of inpatient care , discharge to OPAT reduced hospitalization by 42 + /- 15 % and saved a median of $ 2908 ( 10th to 90th percentile range , $ 1,077 to $ 4,707 ) per patient . CONCLUSION Convalescent phase OPAT is a cost-effective alternative to continued hospitalization for children with complicated appendicitis who are clinical ly stable yet require further parenteral antibiotic therapy Sulbactam is a beta-lactamase inhibitor that , when combined with ampicillin , gives the latter antibiotic a broad spectrum of activity , making it suitable for use as a prophylactic agent in acute appendicitis . In a single-blind , r and omized trial , the efficacy of sulbactam plus ampicillin was compared with that of metronidazole plus cefotaxime .  Thirty-five children undergoing appendectomy received intravenous sulbactam and ampicillin , while 38 children received metronidazole and cefotaxime . Single doses were given unless the appendix was considered gangrenous or perforated , in which case the drugs were administered for 72 hr . There were three wound infections in the group given sulbactam and ampicillin and five in the group given metronidazole and cefotaxime . The combination of sulbactam and ampicillin was well tolerated and appeared to be at least as effective as that of metronidazole and cefotaxime in the prevention of sepsis following appendectomy The efficacy of imipenem-cilastatin was compared with that of tobramycin and metronidazole for the treatment of appendicitis-associated abdominal infections in children in an open , r and omized trial . Two hundred eighteen patients between 2.5 and 16.8 years of age hospitalized for appendectomy because of suspected acute appendicitis were allocated to 5 treatment groups . The appendix was perforated in 54 ( 33.8 % ) of the 160 cases with appendicitis . All patients responded favorably to treatment . Infection in the wound coccurred in 15 of 125 ( 12.0 % ) of those without preoperative A prospect i ve study on the management of severe acute appendicitis with gangrene and perforation was carried out using protocol s that included schematized treatment . The schemes emphasized adequate preoperative treatment , meticulous operative technique of peritoneal toileting , generous use of appropriate antibiotics in combinations , and early grade d patient 's ambulation in the postoperative period . The average hospital stay was seven days , wound infection was of mild degree and less than 1 % , and there was a low morbidity . Follow-up has shown no serious complications Appendectomy for the diagnosis of appendicitis was prospect ively performed upon 133 children from 1 July 1982 to 30 June 1985 with no mortality . The pathologic diagnosis revealed 11 normal appendices ( 8.3 per cent ) , 54 instances of acute appendicitis ( 40.6 per cent ) , 16 instances of gangrenous appendicitis ( 12.0 per cent ) and 52 instances of perforated appendicitis ( 39.1 per cent ) . There were no complications in those patients with normal appendices , acute appendicitis and gangrenous appendicitis and the mean length of hospitalization for these groups was 3.27 , 3.37 and 4.75 days , respectively . The mean length of hospitalization for patients with perforated appendicitis was significantly longer , 9.45 days ( p less than 0.05 ) . Thirteen complications developed in 11 patients with perforated appendicitis . Eight patients required a reoperation ( a major morbidity rate of 15.4 per cent ) . There was only one readmission which occurred three and one-half weeks after discharge for intestinal obstruction . Early appendectomy in children with a presumed diagnosis of either acute or perforated appendicitis result ed in low morbidity rates and is more cost effective than nonoperative management proposed by others due to shorter hospitalization and no planned readmission HYPOTHESIS For children with perforated appendicitis , the use of a prolonged course of intravenous ( i.v . ) antibiotics is equivalent to a short course of i.v . antibiotics followed by sequential conversion to oral ( PO ) antibiotics . DESIGN Prospect i ve , r and omized , clinical trial . SETTING Multicenter study in tertiary children 's hospitals . PATIENTS Children ( aged 5 - 18 years ) with perforated appendicitis found at laparotomy . INTERVENTION Children were r and omized after appendectomy either to a 10-day course of a combination of i.v . ampicillin , gentamicin sulfate , and clindamycin ( n = 10 ) ; or to a short course of a combination of i.v . ampicillin , gentamicin , and clindamycin , followed by conversion to a combination of p.o . amoxicillin and clavulanate potassium plus metronidazole ( n = 16 ) . MAIN OUTCOME MEASURES The primary outcome measure was clinical success , which was rated as complete , partial , or failure . Secondary outcome measures included return of oral intake , duration of fever , return of normal white blood cell count , and patient charges . Treatment equivalence was determined using confidence interval analysis . RESULTS We found treatment equivalence between the i.v . and i.v./p.o . groups , with 6 ( 60 % ) complete and 4 ( 40 % ) partial successes for the 10 patients in the i.v . group and 15 ( 94 % ) complete and 1 ( 6 % ) partial successes for the 16 patients in the i.v./p.o . group ( P < or = .05 ) . There was no difference in return of oral intake , duration of fever , or return of normal white blood cell count between the groups . Conversion to oral therapy results in savings of approximately $ 1500 per case . CONCLUSION There is treatment equivalence between prolonged i.v . therapy and i.v . therapy followed by conversion to oral antibiotic therapy in children with perforated appendicitis OBJECTIVE To compare the therapeutic efficacy of four antibiotic regimens : penicillin , tobramycin , and clindamycin ; penicillin , tobramycin , and ornidazole ; piperacillin alone ; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis . DESIGN Prospect i ve r and omised study . SETTING Teaching hospital , Turkey . SUBJECTS 200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were r and omly assigned to one of four groups each consisting of 50 patients . INTERVENTIONS Preoperative antibiotics given intravenously , peritoneal drainage by Penrose drains without irrigation , appendicectomy with the inversion of the stump by a purse string , taking peritoneal swabs , and primary skin closure . MAIN OUTCOME MEASURES Comparability of the groups , duration of fever , leucocytosis , antibiotic treatment , stay in hospital , nasogastric intubation , and drainage , as well as results of cultures and complications . RESULTS There were no significant differences between the groups for any variable studied . The predominant bacterial species were Escherichia coli , Klebsiella spp , Pseudomonas spp , Fusobacteria , and Peptostreptococci which were appropriately covered by all the antibiotic regimens . Fourteen patients had complications including wound infections ( n = 10 ) , prolonged ileus ( n = 2 ) and intra-abdominal abscess ( n = 2 ) all of which were treated conservatively . There was no mortality and no major complications . All regimens had the same clinical and bacteriological efficacy . CONCLUSION There is no gold st and ard for antimicrobial chemotherapy in perforated appendicitis . Different antibiotic combinations or a single broad spectrum antibiotic , which include both aerobic and anaerobic coverage , can safely be used in children with perforated appendicitis St and ard therapy for childhood ruptured appendicitis includes combination antibiotic therapy with ampicillin , gentamicin and clindamycin . Complicated dosing schedules and the possibility of aminoglycoside toxicity make alternatives desirable . One such alternative is Timentin ( a combination agent of ticarcillin disodium and clavulanate potassium ) . This agent has a more convenient dose schedule than st and ard therapy and eliminates the possibility of aminoglycoside ototoxicity and nephrotoxicity . It is active in vitro against most pathogens associated with ruptured appendicitis in children . The preliminary results of an ongoing prospect i ve , open label , r and omized trial comparing ticarcillin and clavulanate with ampicillin , gentamicin and clindamycin in childhood ruptured appendicitis are reported herein . While further evaluation is necessary , we have found single agent therapy with ticarcillin and clavulanate to be equivalent in safety and efficacy to st and ard combination therapy . Also discussed are the relative merits of immediate versus delayed primary closure of the abdominal wound after appendectomy One hundred children with peritonitis result ing from a perforated appendix were treated with ceftazidime or netilmicin . Metronidazole was added to both groups to treat the anaerobic organisms commonly associated with the infecting aerobic organisms in peritonitis . Escherichia coli was the most common aerobe found in peritoneal pus . Wound infection occurred in nine patients of the netilmicin group and in none treated with ceftazidime ( P less than 0.01 ) . No bacterial resistance was evident in the ceftazidime group , but gram-positive streptococci found in eight patients were resistant to netilmicin . Thus it is recommended that an antibiotic of the penicillin group be added if netilmicin is used to treat peritonitis . The results indicate that ceftazidime was more effective than netilmicin in the treatment of children with peritonitis result ing from a perforated appendix
target: There was no consistency among the protocol s regarding length of antibiotic use , discharge criteria , or use of home antibiotics following discharge .
  Limiting duration of antibiotic use to3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection .
  In the absence of higher-level evidence , shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe
background: The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated .