Evidence-based Clinical
Practice Guidelines for
Acute Nontraumatic RLQ
Abdominal Pain and Tenderness and
Acute Appendicitis
If we have to give antibiotics in a patient for appendectomy, what, when, and how long?
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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?) |
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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 |
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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 |
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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.
*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 |
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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. |
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· Total no. of papers and abstracts appraised: · Level of evidences:
Tracking and
Retrieval Results:
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Presentation
of Primary Evidences:
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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. |
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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? |
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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. |