A Single-Center Assessment of the Antibiotic Therapy Protocol for Pediatric Patients With Complicated Appendicitis

Abstract Background The treatment of children with complicated appendicitis (CA) involves administering intravenous antibiotics for several days to prevent postoperative complications. Since 2013, our institutional postoperative management protocol for CA in children has recommended Ceftriaxone/Metronidazole (CM) as the first-line treatment. According to the protocol, if a fever >38.5°C occurs 72 hours after the surgery, a switch to Piperacillin/Tazobactam (PT) is indicated and PT is continued for an additional 5-7 days. Fever is the only criterion used to initiate the CM to PT switch. Aims This study aims to identify factors that predict the need to switch from CM to PT, enabling PT to be considered as a primary treatment option for more effective management. Methods This retrospective study included children aged 0–16 years with CA, treated according to our institutional antibiotic protocol, from 1/2013 to 12/2023. Collected data included patient demographics, medical history, biomarkers, imaging findings, appendix characteristics, surgical details, antibiotics, and additional treatments. Variables were analyzed at three time points: T0, pre-operative assessment; T1, peri-operative period; and T2, first 72 hours post-operatively. Results A total of 256 children were included in the study, median age at surgery 10 years (interquartile range: 7–13). Thirty-nine patients (15%) underwent antibiotic switch, while 217 (85%) did not. Factors significantly (p > 0.05) associated with switch included: at T0, generalized peritonitis, dehydration necessitating intravenous fluid bolus, elevated C-reactive protein levels, imaging findings of collections and/or stercolith; at T1, the presence of intra-abdominal abscesses, and prolonged anesthesia and/or surgical duration; at T2, a higher frequency of febrile peaks >38.5°C. Conclusion 15% of children with CA required a switch from CM to PT. Several factors appear to predict the need for this adjustment. Patients showing these characteristics are at a higher risk of insufficient response to CM and may benefit from primary treatment with PT.