Tuesday, August 25, 2015

In 22% of kids with appendicitis, antibiotics do not prevent perforation

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.


Louis said...

Hope a lot of processing docs see this and realize how dumb he recent stuff about treatment without surgery is. Of course, a lot of patients with be ok. Some would get well without any treatment. But why risk the ones who won't? L Browning M.D. ( long retired, so no personal gain involved! )


Skeptical Scalpel said...

Lou, thanks for commenting. I agree with you.

artiger said...

Don't worry, there will always be some gamblers out there who are willing to risk recurrence and treatment failure for minimal (if any) gain. These "volunteers" will help provide further evidence for what actually works. Let's not discourage them.

Seriously, we should always include data as mentioned above in all discussions with patients, prior to operative intervention. If the patient wants to make a bad decision, that is his/her choice, but our charge is to provide them with understandable information, which is easier in some locations than others.

Skeptical Scalpel said...

Artiger, I don't agree. If you really feel a treatment is inferior, you should tell the patient. I would tell the patient about the recent Finnish study but point out its flaws. I would then say I recommend surgery and would not want any member of my family to be treated only with antibiotics. Then if the patient wants the antibiotics, that's fine with me.

artiger said...

Scalpel, isn't that what I said?

Skeptical Scalpel said...

I'm not sure. :-)

A. Banterings said...

In some of these cases, we must ask is it truly appendicitis and if so what is the cause? If it is blocked by stool, a foreign body, or cancer, then surgery is the only option.

If the blockage is from infection (since the appendix swells in response to any infection in the body,) one can see why antibiotics work. Infection goes away, swelling goes down, appendix is unblocked. (That is a overly-simplistic explanation.)

I think that if we were to study the cause of the blockage, have a way to determine it, then we would probably see that there are only certain types that respond to antibiotics.

Failure to investigate this more and simply rely on surgery does just as much an injustice to the patient as always preforming surgery. There is obviously potential here, just not enough of the right research yet.

Remember that I’m medicine it is not what we know, but what we think that we know…

Skeptical Scalpel said...

Unless a fecalith is present, there is no reliable way to tell if the appendix is obstructed or what the cause is. I don't know how one could study this. CT scans that don't show fecaliths would be of no value.

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