Appendicitis
Conditions
Keywords
antibiotic, antimicrobial, stewardship, child
Brief summary
Acute appendicitis is a common surgical emergency in children. Non-perforated appendicitis patients do not require antibiotics after appendectomy. Although guidelines and recommendations exist to decrease post-operative antibiotic mis-use after appendectomy, surgeons continue to prescribe unwarranted antibiotics. The aim of this study is to determine if an Antimicrobial Stewardship Program in Pediatric Surgery will decrease the use of un-warranted antibiotics.
Detailed description
Many surgeons continue to treat non-perforated or borderline perforated appendicitis with postoperative antibiotics despite an evidence-based definition of perforation (in the pediatric surgical literature) and many guidelines and recommendations that specify that no postoperative antibiotics are required. Children with perforated appendicitis are also often treated with longer-than-necessary courses of antibiotics. Although surgeons may feel that they only prescribe additional doses on occasion, evidence suggests that this behavior occurs in over 50% of children with non-perforated appendicitis. These additional doses contribute to a longer length of stay, excess costs to the health care system, and disrupt patient flow. Additionally, the patients are exposed to more antibiotics and their potential for adverse effects (such as incorrect dose, incorrect medication, allergic reaction, antimicrobial resistance or c difficile infection). Antimicrobial stewardship programs have been successful in pediatrics and adult general surgery in curbing unwarranted antibiotic use, but have never been evaluated in pediatric general surgery.
Interventions
OTHERAntimicrobial Stewardship Program
Twice weekly meeting with Infectious Disease and Pediatric Surgery team members to audit antibiotics prescribed and suggest role for discontinuation.
Sponsors
Alberta Children's Hospital
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
No minimum to 18 Years
Healthy volunteers
Yes
Inclusion criteria
* Participant (surgeon) is a pediatric surgeon at McMaster Children's Hospital and takes care of patients under the age of 18 who undergo appendectomy. * Participant (surgeon) is able to read, write and understand English. * Participant (surgeon) is able to provide informed consent.
Exclusion criteria
* Participant (surgeon) only has patients who undergo drain insertion, PICC line insertion or a secondary operation during the same admission * Participant (surgeon) only has patients who do not undergo operation (i.e. conservative management with interval appendectomy) * Participant (surgeon) does not provide informed consent * Participant (surgeon) does not understand written and spoken English diagnosis other than appendicitis at time of operation
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Compliance with American Pediatric Surgical Association recommendations for postoperative antibiotics for appendicitis | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | Includes both intravenous and oral antibiotics prescribed, both during the time frame from admission until discharge, in addition to any prescription given for home, oral antibiotics. Measured as yes/no |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Postoperative intravenous antibiotics for non-perforated appendicitis | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | measured as number of days (ie number of doses divided by number of doses-per-day) |
| Postoperative oral antibiotics for non-perforated appendicitis | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | measured as number of days (ie number of doses divided by number of doses-per-day) |
Other
| Measure | Time frame | Description |
|---|---|---|
| Drain insertion | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | Need for a drain insertion (by interventional radiology) for postoperative abscess, measured as yes/no |
| Re-operation | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | Need for re-operation on the same admission, measured as yes/no |
| Length of Stay | Length of admission | Measured in days (from date of admission until date of discharge) |
| Postoperative fever | Length of admission | Rectal temperature above 100.4ºF (38ºC), measured as yes/no and on what postoperative day Oral temperature above 100ºF (37.8ºC) Axillary (armpit) temperature above 99ºF (37.2ºC) Ear (tympanic membrane) temperature above 100.4ºF (38ºC) in rectal mode or 99.5ºF (37.5ºC) in oral mode Forehead (temporal artery) temperature above 100.4ºF (38ºC) |
| Wrong medication/Wrong dose | From date of admission until date of first follow-up visit, typically within 4-6 weeks of discharge | Measured as yes/no in addition to description of problem (wrong dose, wrong medication) |
| C difficile infection | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | Measured as yes/no based on stool assay |
| Adverse reaction to antibiotic | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | Measured as yes/no in addition to description of reaction (eg hives, shortness of breath) |
| Readmission within 30 days | Within 30 days of discharge | Need for readmission within 30 days of discharge, measured as yes/no |
| Peripherally inserted intravenous catheter (PICC) | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge | Need for PICC insertion for long term antibiotics, intravenous fluids or parenteral nutrition, measured as yes/no |
Outcome results
None listed