Duration of Postoperative Intravenous Antibiotics in Childhood Complicated Appendicitis: A Propensity Score-Matched Comparison Study

INTRODUCTION: Postoperative antibiotics complement surgery in managing childhood-complicated appendicitis. However, there is limited evidence to guide clinicians on appropriate duration of therapy. A comparison cohort study was performed to determine whether tailoring duration of inpatient intravenous (IV) antibiotic therapy to patient response, assessed using a set of clinical criteria, leads to shortened hospital length of stay (LOS) without compromising patient outcomes. PATIENTS AND METHODS: Over a 6-month period, 47 children (aged 5-14 years) with complicated appendicitis were treated with postoperative IV antibiotics until each satisfied a set of bedside clinical parameters suggesting resolved intraperitoneal infection (core temperature < 38°C for 24 hours, tolerated two consecutive meals, mobilizing independently, requiring only oral analgesia). Complicated appendicitis was defined as the presence of generalized peritonitis, appendiceal perforation or gangrene, and/or abscess. Postoperative recovery parameters were prospectively recorded and compared with those of 47 historical control patients, matched by propensity scores, who received 5 days minimum of postoperative IV antibiotics. Sample size was determined by a priori power calculation based on reduction in LOS. Severity of postoperative complications was graded using the Clavien-Dindo system. RESULTS: Study group variables were comparable including patient demographics, duration of presenting symptoms, severity of presenting disease, preoperative antibiotics received, length of operation, seniority of primary surgeon, surgical approach taken, and intraoperative findings. The prospective cohort had a significantly shorter median LOS compared with the historical control cohort (5 vs. 6 nights, p = 0.010) while readmission rates and the incidence and severity of complications were similar, including incidence of postoperative intra-abdominal infections (6 vs. 8 cases, p = 0.562). CONCLUSION: Using bedside clinical parameters indicative of resolved intraperitoneal infection to tailor duration of postoperative IV antibiotics for children with complicated appendicitis shortens LOS without apparent compromise to patient outcomes.