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Evidence-based Clinical Practice Guidelines for

Acute Nontraumatic RLQ Abdominal Pain and Tenderness and

Acute Appendicitis

 

Clinical Issue/Question
 

If we have to give antibiotics in a patient for appendectomy, what, when, and how long?

 

Format of Guidelines Development

 

·        Evidence Appraisal Plan

·        Search and Tracking Outcome

·        Quick Reference Guide or Algorithm

 

 

Clinical Scenario and Issue

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With a pretreatment diagnosis of acute appendicitis, and

With a plan of operative treatment,

 

If we have to give antibiotics, what is the most cost-effective regimen (what, when, and how long?)

 

 

Statement of Premises:

 

In treating non-immunocompromised patients with acute appendicitis, if we have to give antibiotics, what, when, and how long do we give?

 

Immunocompromised patients consist of patients with AIDS, cachexia, and other severe systemic diseases, such as diabetes, renal and vascular insufficiency.

 

Acute appendicitis means patients with focal right lower quadrant  (RLQ) peritoneal irritation or peritonitis secondary to an appendicitis.  This excludes generalized peritonitis as manifested by diffuse abdominal rigidity.  The appendicitis may be active mural appendicitis, phlegmonous appendicitis, suppurative appendicitis, gangrenous appendicitis, and perforated appendicitis with RLQ peritonitis.

 

Antibiotics as used here will be as an adjuvant treatment to appendectomy, not as the primary treatment.

 

Antibiotics have the potential to control systemic infection associated with appendicitis.  However, since systemic complications are rare with acute appendicitis, antibiotics given as an adjuvant treatment to appendectomy are used primarily to reduce incisional wound infection.

 

Goal of antibiotic administration as an adjunct to operative treatment of acute appendicitis: to prevent wound infection

 

 

Operational Definition of Terms in the Issue/Question:

 

·        Antibiotic treatment – any regimen given in conjunction to appendectomy

 

·        Cost-effective antibiotic regimen – the best after weighing the benefit-risk-cost-availability factors of various antibiotic regimens

 

 

Evidence Appraisal Plan:

 

End-points in answering the question:

 

·        The most cost-effective antibiotic regimen – what, when, and how long – after analysis of benefit-risk-cost-availability factors

 

Approaches in answering the question:

 

·        Look for randomized control trials  (RCTs) on use of antibiotics as an adjuvant to appendectomy in the prevention of wound infection.

·        Compare cost and availability factors in the Philippines.

 

Antibiotics

Benefit/Efficacy

Risk

Cost*

Availability

Regimen 1

 

Side-effects of antibiotics

 

 

Regimen 2

 

Side-effects of antibiotics

 

 

*Cost – private setting 

 

·        Consider the different stages of appendicitis in the analysis.

Early Appendicitis:

            Grossly normal

            Acute appendicitis

            Suppurative appendicitis

            Phlegmonous appendicitis

            Nonperforated appendicitis

Advanced Appendicitis:

Gangrenous appendicitis

            Perforated appendicitis

 

 

 

Search Methodology:

 

Tracking:

            Medline – for international journal publications

            Herdin – for local journal publications

            Internet using various search engines such as AltaVista, Infoseek, Lycos, etc.

 

Retrieval:

Retrieval of whole journal article was done through the various libraries of the Metro Manila medical schools, Department of Science and Technology (DOST), and acquaintances.

 

Appraisal (Inclusion Criteria):

 

·        Focus of paper is on use of antibiotic in conjunction with appendectomy as treatment for acute appendicitis

·        With gold standard (intraoperative findings, histopathological results, follow-up)

·        More than 30 subjects

·        With data at least on wound infection.

 

 

Search and Tracking Outcome:

·        Total no. of papers and abstracts appraised: 

·        Level of evidences:

 

Tracking and Retrieval Results:

 

Database

Search engine

Search span

Search words

No. of titles

Relevant abstracts/papers

Medline

1966-1999 (July)

 Ap +  Antibiotics

 54

29

 

 

 Ap + Preop Antibiotics 

 39

 22

 

1966-1999

(August)

Ap + Wound Infections

203

112

 

 

Ap + Treatment with no antibiotics + RCT

23

6

Herdin

 

Appendicitis

   107

 0

AltaVista, Infoseek, Lycos, etc

 

Appendicitis

tntc

 1

 

 

 

 

 

Presentation of Primary Evidences:

 

Children – Early Appendicitis – Wound Infection Rate

Authors

Year

N

Without Antibiotics

With Antibiotics

Söderquist Elinder et al  (Sweden)

1995

544

=

=

Kizilcan et al (Turkey)

1992

100

=

=

Hutchinson et al (USA)

1983

133

=

=

 

 

All Ages – Early Appendicitis – Wound Infection Rate

Authors

Year

N

Without Antibiotics

With Antibiotics

 Bauer T et al (Denmark)

 1989

 1735

 

 Significant reduction

 

 

 

 

 

 Pinto et al (UK)

 1980

263

 7%

 5%

 

 

 

 

 

Giacomantonio et al (Canada)

 1982

20

=

=

 

 

Children – Advanced Appendicitis – Wound Infection Rate

Authors

Year

N

Without Antibiotics

With Antibiotics

Söderquist Elinder et al  (Sweden)

1995

544

14%

1.8 /3%

 

 

All Ages – Advanced Appendicitis – Wound Infection Rate

Authors

Year

N

Without Antibiotics

With Antibiotics

 Bauer T et al (Denmark)

 1989

 1735

 

 Significant reduction

 

 

 

Distillation of all available evidences to come out with recommendations or answers to the clinical issue/question:

 

There is no advantage of antibiotics in early appendicitis.

 

There is an advantage of antibiotics in advanced appendicitis.

 

 

 Summary of Answer to Question or Recommendations:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With a pretreatment diagnosis of acute appendicitis, and

With a plan of operative treatment,

 

If we have to give antibiotics, what is the most cost-effective regimen (what, when, and how long?)

 

Give antibiotics only to patients with advanced appendicitis.

 

The what, when and how long have no definite answers yet.

 

 

 

Future Research Issues/Questions Arising from Attempts to Answer Issue:

 

Can leaving the wound open in advanced appendicitis prevent wound infection that there is no need for antibiotics?

 

 

 

References:

 

Title:

Prophylactic antibiotics in uncomplicated appendicitis during childhood--a prospective randomised study.

Author

Söderquist Elinder C; Hirsch K; Bergdahl S; Rutqvist J; Frenckner B

Address

Department of Paediatric Surgery, St. GÂoran's Children's Hospital, Karolinska Institute, Stockholm, Sweden.

Source

Eur J Pediatr Surg, 1995 Oct, 5:5, 282-5

 

 

Title

The necessity of prophylactic antibiotics in uncomplicated appendicitis during childhood.

Author

Kizilcan F; Tanyel FC; Büyükpamukçu N; Hiçsönmez A

Address

Department of Pediatric Surgery, Hacettepe University, Children's Hospital, Ankara, Turkey.

Source

J Pediatr Surg, 1992 May, 27:5, 586-8

 

 

Title

A double-blind controlled trial of metronidazole suppositories in children undergoing appendicectomy.

Author

Hutchinson GH; Patel BG; Doig CM

Address

Source

Curr Med Res Opin, 1983, 8:6, 441-5

 

 

Title

Antibiotic prophylaxis in acute nonperforated appendicitis. The Danish Multicenter Study Group III.

Author

Bauer T; Vennits B; Holm B; Hahn Pedersen J; Lysen D; Galatius H; Kristensen ES; Graversen P; Wilhelmsen F; Skjoldborg H; et al

Address

Department of Surgery, General Hospital of Roenne, Denmark.

Source

Ann Surg, 1989 Mar, 209:3, 307-11

 

 

Title

Prophylactic metronidazole in prevention of infection after appendicectomy: report of a double-blind trial.

Author

Gottrup F

Address

Source

Acta Chir Scand, 1980, 146:2, 133-6

 

 

Title

Rational use of antibiotic therapy after appendicectomy.

Author

Pinto DJ; Sanderson PJ

Br Med J, 1980 Feb, 280:6210, 275-7

 

 

Title

Should prophylactic antibiotics be given perioperatively in acute appendicitis without perforation?

Author

Giacomantonio M; Bortolussi R; Gillis DA

Address

Source

Can J Surg, 1982 Sep, 25:5, 555-6

 

 

Title

The place of antibiotics in the prevention of post-appendicectomy sepsis: a prospective study of 400 cases.

Author

el Sefi TA; el Awadi HM; Shehata MI; Al Hindi MA

Address

Source

Int Surg, 1986 Jan, 71:1, 18-21

 

 

Title

Effect of prophylactic antibiotics in acute nonperforated appendicitis: a prospective, randomized, double-blind clinical study.

Author

Busuttil RW; Davidson RK; Fine M; Tompkins RK

Address

Source

Ann Surg, 1981 Oct, 194:4, 502-9

 

 

Title

Wound management in perforated appendicitis.

Author

Lemieur TP; Rodriguez JL; Jacobs DM; Bennett ME; West MA

Address

Department of Surgery, Hennepin County Medical Center, University of Minnesota, Minneapolis, USA.

Source

Am Surg, 1999 May, 65:5, 439-43

 

Title

Primary appendectomy. The effect of prophylatic cephaloridine on postoperative wound infection.

Author

Foster PD; OToole RD

Address

Source

JAMA, 1978 Apr, 239:14, 1411-2

 

 

Title

Acute nonperforating appendicitis. Efficacy of brief antibiotic prophylaxis.

Author

Winslow RE; Dean RE; Harley JW

Address

Source

Arch Surg, 1983 May, 118:5, 651-5

 

 

Title

Prevention of post-operative infection in appendicectomy by single dose intravenous metronidazole. An open prospective randomised study.

Author

Kling PA; Holmlund D; Burman LG

Address

Source

Acta Chir Scand, 1985, 151:1, 73-6

 

 

 

 

Quick Reference Guide or Algorithm:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With a pretreatment diagnosis of acute appendicitis, and

With a plan of operative treatment,

 

If we have to give antibiotics, what is the most cost-effective regimen (what, when, and how long?)

 

Give antibiotics only to patients with advanced appendicitis.

 

The what, when and how long have no definite answers yet.