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 Kansas City 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
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.