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Completed Prospective Studies Prospective Randomized Evaluation of Antibiotic Regimens Following Appendectomy for Perforated Appendicitis

Single Daily Dosing Ceftriaxone and Metronidazole vs Standard Triple Antibiotic Regimen for Perforated Appendicitis in Children: A Prospective Randomized Trial (Shawn D. St. Peter, Kuojen Tsao, Troy L. Spilde, George W. Holcomb III, Susan W. Sharp, J. Patrick Murphy, Charles L. Snyder, Ronald J. Sharp, Walter S. Andrews, Daniel J. Ostlie) Journal of Pediatric Surgery 2008;43:981-985.

A retrospective review at Children's Mercy Hospitals and Clinics found ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy than traditional triple antibiotic therapy (ampicillin, gentamicin, clindamycin; AGC) for perforated appendicitis. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these two regimens.

Children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (two total doses/day) or standard dosing of AGC (11 total doses/day). Perforation was defined as an identifiable hole in the appendix or stool in the abdomen.

The operative approach (laparoscopic), length of antibiotic usage and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary endpoint, a sample size of 100 patients was calculated for an alpha of 0.5 and a power of 0.82. Thus, 100 patients were enrolled. One case was converted to an open operation. Two patients were excluded, one due to surgical failure (retained fecalith) and the other due to transfer to another hospital prior to completion of the antibiotic course. On presentation, there were no differences in gender distribution, days of symptoms, temperature or leukocyte counts between the two groups.

Conclusion: There was no difference in time to regular diet, length of hospitalization, percentage of postoperative abscess or percentage of wound infection. The antibiotic charges, however, were dramatically higher in the three-drug regimen (P < 0.001). Therefore, once daily dosing with the two drug regimen (CM) was found to offer a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional three-drug regimen.

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