Post-discharge oral home antibiotic use in complicated pediatric appendicitis: a systematic review and meta-analysis

BACKGROUND: The use of oral home antibiotics after discharge in children undergoing surgery for complicated acute appendicitis remains controversial. This systematic review and meta-analysis aimed to evaluate whether oral home antibiotics reduces the risk of infectious complications or readmissions compared to patients discharged without antibiotics. METHODS: This systematic review was prospectively registered in PROSPERO (CRD420251049919). We searched PubMed, Web of Science, Scopus, Ovid and Cochrane CENTRAL from inception to March 2025. Two independent reviewers screened the identified studies, extracted the data and assessed the methodological quality using the risk of bias in non-randomized studies-of intervention tool. Eight random-effects meta-analyses and four leave-one-out meta-analyses were conducted for intra-abdominal abscesses, surgical site infections, organ/space infections and hospital readmissions. Two exploratory random-effects meta-regression models were performed for readmissions. Certainty of evidence for all outcomes was formally assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Fourteen studies comprising 26,174 pediatric patients with complicated acute appendicitis were included. Meta-analyses showed no significant differences between intervention and comparator groups for intra-abdominal abscesses risk ratio (RR) 1.23; 95% confidence interval (CI) 0.62-2.46, organ/space infections (RR 1.19; 95% CI 0.73-1.93), or readmissions (RR 1.07; 95% CI 0.78-1.45). In exposure-restricted analyses, no home antibiotic patients had a modestly lower risk of readmission (RR 0.78; 95% CI 0.61-1.01, P = 0.05). The risk of surgical site infections was significantly higher among patients in the control group (RR 0.77; 95% CI, 0.61-0.96; P = 0.02). However, this apparent association was not robust and was lost in sensitivity analyses restricted to studies with crude patient-level exposure data, where the effect reversed direction (RR > 1), consistent with protocol-based confounding. Across all outcomes, certainty of evidence was rated very low, primarily driven by potential confounding by indication and non-randomized designs. CONCLUSIONS: Oral home antibiotics after discharge does not appear to reduce the risk of postoperative complications in children treated surgically for complicated acute appendicitis. Given the lack of consistent benefit and potential for unnecessary harm, routine use of post-discharge oral home antibiotics is not supported. Exposure-restricted analysis also raises a plausible signal of harm in terms of readmissions. Because certainty of the evidence is very low, further high-quality prospective studies are needed to define the true effect of oral home antibiotics in this context.