Comparative trial of four antibiotic combinations for perforated appendicitis in children

Abstract

Objective: To compare the therapeutic efficacy of four antibiotic regimens: penicillin, tobramycin, and clindamycin; penicillin, tobramycin, and ornidazole; piperacillin alone; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis.

Design: Prospective randomised study.

Setting: Teaching hospital, Turkey.

Subjects: 200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were randomly assigned to one of four groups each consisting of 50 patients.

Interventions: Preoperative antibiotics given intravenously, peritoneal drainage by Penrose drains without irrigation, appendicectomy with the inversion of the stump by a purse string, taking peritoneal swabs, and primary skin closure.

Main outcome measures: Comparability of the groups, duration of fever, leucocytosis, antibiotic treatment, stay in hospital, nasogastric intubation, and drainage, as well as results of cultures and complications.

Results: There were no significant differences between the groups for any variable studied. The predominant bacterial species were Escherichia coli, Klebsiella spp, Pseudomonas spp, Fusobacteria, and Peptostreptococci which were appropriately covered by all the antibiotic regimens. Fourteen patients had complications including wound infections (n = 10), prolonged ileus (n = 2) and intra-abdominal abscess (n = 2) all of which were treated conservatively. There was no mortality and no major complications. All regimens had the same clinical and bacteriological efficacy.

Conclusion: There is no gold standard for antimicrobial chemotherapy in perforated appendicitis. Different antibiotic combinations or a single broad spectrum antibiotic, which include both aerobic and anaerobic coverage, can safely be used in children with perforated appendicitis.