From the Division of Infectious Disease, Department of Pediatrics.
Department of Surgery.
Pediatr Infect Dis J. 2019 Nov;38(11):e290-e294. doi: 10.1097/INF.0000000000002420.
Antimicrobial stewardship interventions to curtail the use of third-generation cephalosporins and antipseudomonal penicillins for the treatment of complicated appendicitis in children are challenging given the tendency to treat complicated disease with broad-spectrum antimicrobials. Reasons for this are unclear, but there is a paucity of contemporary microbiologic data associated with the child presenting with either acute perforated or gangrenous appendicitis. This study aimed to justify the appropriateness of an empiric regimen consisting of ampicillin, tobramycin/gentamicin plus metronidazole and to analyze duration of postoperative therapy.
We conducted a retrospective cohort study from February 1, 2017, to October 31, 2018, in children who underwent appendectomy or interventional radiologic drainage for primary complicated appendicitis. The primary outcome was the proportion of patients who had a pathogen isolated from peritoneal fluid culture that was not susceptible to the recommended empiric therapy. The secondary outcomes were the total duration of antimicrobial therapy and the proportion of patients with a postoperative infectious complication within 30 days after intervention.
Of 425 children with primary acute appendicitis, 158 (37%) had complicated appendicitis at presentation. Culture was performed in 53 (40%) of the 133 who underwent a surgical or interventional radiologic intervention. The group with peritoneal cultures was more likely to present with longer symptom duration before admission [3 (interquartile range, 2-5) vs 2 (interquartile range, 1-2) days; P < 0.001] and with purulent peritonitis [47% (25/53) vs 13% (10/80); P < 0.001]. The most common pathogens isolated were anaerobes (81%), Escherichia coli (74%) and Streptococcus anginosus group (62%). Only 4% of isolated bacteria were resistant to empiric therapy. Postoperative infectious complications were documented in 23 (17%) patients and were not associated with the presence of a resistant pathogen or the choice of antimicrobial agents but with more severe disease and higher C-reactive protein values (303 vs 83 mg/L; P=0.03) at presentation.
In a cohort of previously healthy children presenting with complicated appendicitis requiring surgical drainage, the most common bacteria from peritoneal cultures continue to be S. anginosus, aminoglycoside-susceptible Gram-negative bacilli and anaerobes. In an attempt to reduce extended-spectrum cephalosporin use, these data were useful in supporting the use of metronidazole with ampicillin and an aminoglycoside, rather than third-generation cephalosporins.
鉴于治疗复杂性阑尾炎时使用广谱抗生素的趋势，控制第三代头孢菌素和抗假单胞菌青霉素的使用以进行抗菌药物管理具有挑战性。原因尚不清楚，但目前与急性穿孔或坏疽性阑尾炎患儿相关的微生物数据很少。本研究旨在确定氨苄西林、妥布霉素/庆大霉素加甲硝唑经验性治疗方案的合理性，并分析术后治疗时间。
我们进行了一项回顾性队列研究，纳入 2017 年 2 月 1 日至 2018 年 10 月 31 日期间因原发性复杂性阑尾炎而行阑尾切除术或介入放射学引流的患儿。主要结局是从腹腔液培养中分离出的病原体对推荐的经验性治疗方案耐药的比例。次要结局是抗菌药物治疗的总持续时间和术后 30 天内发生感染性并发症的患者比例。
在 425 例原发性急性阑尾炎患儿中，158 例（37%）就诊时表现为复杂性阑尾炎。在 133 例接受手术或介入放射学干预的患儿中，53 例（40%）进行了培养。进行腹腔培养的患儿就诊前症状持续时间更长[3（四分位间距，2-5）比 2（四分位间距，1-2）天；P＜0.001]和更可能表现为脓性腹膜炎[47%（25/53）比 13%（10/80）；P＜0.001]。分离出的最常见病原体为厌氧菌（81%）、大肠埃希菌（74%）和咽峡炎链球菌组（62%）。仅 4%的分离细菌对抗菌药物治疗耐药。23 例（17%）患儿发生术后感染性并发症，与耐药病原体的存在或抗菌药物的选择无关，但与更严重的疾病和更高的 C 反应蛋白值（303 比 83mg/L；P=0.03）有关。
在一组需要手术引流的、既往健康的复杂性阑尾炎患儿中，从腹腔液培养中分离出的最常见细菌仍然是咽峡炎链球菌、氨基糖苷类敏感革兰阴性杆菌和厌氧菌。为了减少第三代头孢菌素的使用，这些数据有助于支持使用甲硝唑联合氨苄西林和氨基糖苷类药物，而不是第三代头孢菌素。
