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Treatment With Oral Antibiotics At Discharge in Children With Advanced Appendicitis Is Preferable to Continued Intravenous Therapy

Saturday, October 26, 2013
Windermere Ballroom X (Hyatt Regency Orlando, formerly the Peabody)
Sara C. Fallon, MD, Charlene L. Hallmark, RN, Kathleen E. Carberry, Wei Zhang, PhD, J. Ruben Rodriguez, MD, MS, Mary L. Brandt, MD, FAAP, David E. Wesson, MD and Monica E. Lopez, MD, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine,, Houston, TX

Purpose

The optimal duration and route of antibiotic therapy and timing of discharge in children with advanced appendicitis (gangrenous or perforated) has not been established. Our practice is to discharge patients without antibiotics if they meet clinical criteria and do not have leukocytosis or bandemia. Patients with persistent leukocytosis or bandemia remain hospitalized for continued IV antibiotics or discharged on oral antibiotics at the physician's discretion. We hypothesized that inpatient IV antibiotic therapy in patients clinically ready for discharge results in increased resource utilization without decreasing infectious complications.

Methods

Using a propensity score model including the covariates of age, gender, BMI, white blood cell count (WBC) at admission, duration of symptoms, intraoperative diagnosis (gangrenous, perforated, perforated with abscess), WBC, band count and intraabdominal abscess (IAA) prior to clinical readiness for discharge, we matched patients treated from 7/2011-7/2012 based on their calculated probability of receiving oral vs. IV antibiotics at the time of discharge readiness. Outcomes included IAA formation, length of hospital stay, and imaging use. 

Results

Of 431 children treated for advanced appendicitis during the study period, 281 had persistent leukocytosis or bandemia at clinical readiness for discharge. The outcomes after propensity matching (n=72 in each group) are presented in Table 1. Patients discharged with oral antibiotics had a shorter initial and total hospital length of stay and decreased number of ultrasounds without an increase in late IAA formation or readmissions.

Conclusion

Inpatient intravenous antibiotic therapy for patients clinically ready for discharge with persistent leukocytosis and bandemia increases resource utilization without improving outcomes compared to outpatient treatment with oral antibiotics.  

Table 1

 

Discharge w. Oral Antibiotics

(n = 72)

ContinuedIn Hosp IV Antibiotics

(n  = 72)

P-value

Initial Length of Stay (days)

7.5

10.1

<0.0001

Total number of hospital days

8.5

10.3

0.0007

IAA (Percutaneous drainage)

6.9%

13.9%

0.17

IAA

(Perc drain or antibiotics)

15.3%

20.8%

0.34

Readmission related to appendicitis

16.7%

9.7%

0.22

Post-operative ultrasound

30.6%

47.2%

0.04

Post-operative CT scan

20.8%

22.2%

0.84