AAP Paper
Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

https://doi.org/10.1016/j.jpedsurg.2008.02.018Get rights and content

Abstract

Introduction

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.

Methods

After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an α of .5 and a power of 0.82.

Results

One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.

Conclusions

Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

Section snippets

Methods

Approval was obtained from the Children's Mercy Hospital internal review board (IRB) (IRB no. 04 12-149) before enrolling patients in this study. Patients were subsequently enrolled only after obtaining consent from the patient's legal guardian. The consent forms and consent process were carefully evaluated by the IRB on a continual basis.

Results

From April 2005 to November 2006, 100 patients were enrolled in the study. Two patients were dropped from the study. One was because of surgical failure because of a retained fecalith not removed at the initial operation. The other was because of an urgent family need to transfer the patient to a facility closer to their home before the postoperative course was complete.

Discussion

Triple antibiotic therapy for perforated appendicitis is still common practice in pediatric surgery despite several reports of simpler antibiotic regimens [3], [4], [5]. Monotherapy with newer broad-spectrum agents such as piperacillin/tazobactam for intraabdominal infections has recently been shown to be equally efficacious as traditional triple therapy [3], [4]. Similarly, cefotaxime, a cephalosporin with a similar profile to ceftriaxone, has been shown to be equal to the aforementioned

Acknowledgments

We thank Drs Patricia A. Valusek and Scott J. Keckler, whose efforts made the completion of this study possible.

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