Those clambering aboard the "antibiotics for appendicitis" bandwagon should read this interesting paper about appendicitis in children.
A group of emergency physicians from Maimonides Medical Center in Brooklyn, New York found that "Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendicitis perforation in children who present with CT-documented uncomplicated appendicitis."
Children with simple appendicitis who were taken to the operating room longer than 9 hours from the time of ED presentation were much more likely to develop a perforation than those who had surgery in less than 9 hours.
During the four years of the study, 404 consecutive children ≤ 18 years of age had a CT scan diagnosis of acute appendicitis; 156 (38.6%) had evidence of perforation at the time of presentation and were not included in the final analysis.
All of the remaining 248 patients without perforation underwent appendectomy after IV antibiotics were started in the ED; 244 were treated with piperacillin/tazobactam, and 4 got metronidazole/clindamycin. In 94% of these patients, pre-hospital symptom duration was 2 days or less.
Perforation was found in 54 (21.8%) of the 248 patients. The probability of perforation increased over time as shown in this figure.
For both univariate and multivariate analyses, mean time from ED presentation to appendectomy, presence of an appendicolith, and presence of fever were significantly associated with developing perforation.
Patients with perforations had significantly longer median hospital stays, 5 days vs. 1 day and significantly more postoperative x-ray studies.
Like all studies, this one had some limitations. It was a retrospective, from a single hospital, and the rate of perforation in the original cohort of 404 patients was very high.
In an email to Skeptical Scalpel, lead author Dr. William Bonadio said, "Since working here during the past 5 years, I have been surprised at the incredible volume of pediatric appendicitis that we see. Our overall rate of perforation is in the 30-35% range on admission diagnosis."
This analysis of a large series of children with uncomplicated appendicitis found that antibiotics did not stop the progression of disease to perforation in almost 22% of patients, and the longer the in-hospital delay to operation, the more likely was the occurrence of a perforation.