Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic

Abstract

Objective Early presentation and prompt diagnosis of acute appendicitis are necessary to prevent progression of disease leading to complicated appendicitis. We hypothesize that patients had a delayed presentation of acute appendicitis during the COVID-19 pandemic, which affected severity of disease on presentation and outcomes. Patients and methods We conducted a retrospective review of all patients who were treated for acute appendicitis at Morgan Stanley Children's Hospital (MSCH) between March 1, 2020 and May 31, 2020 when the COVID-19 pandemic was at its peak in New York City (NYC). For comparison, we reviewed patients treated from March 1, 2019 to May 31, 2019, prior to the pandemic. Demographics and baseline patient characteristics were analyzed for potential confounding variables. Outcomes were collected and grouped into those quantifying severity of illness on presentation to our ED, type of treatment, and associated post-treatment outcomes. Fisher's Exact Test and Kruskal-Wallis Test were used for univariate analysis while cox regression with calculation of hazard ratios was used for multivariate analysis. Results A total of 89 patients were included in this study, 41 patients were treated for appendicitis from March 1 to May 31 of 2019 (non-pandemic) and 48 were treated during the same time period in 2020 (pandemic). Duration of symptoms prior to presentation to the ED was significantly longer in patients treated in 2020, with a median of 2 days compared to 1 day (p = 0.003). Additionally, these patients were more likely to present with reported fever (52.1% vs 24.4%, p = 0.009) and had a higher heart rate on presentation with a median of 101 beats per minute (bpm) compared to 91 bpm (p = 0.040). Findings of complicated appendicitis on radiographic imaging including suspicion of perforation (41.7% vs 9.8%, p < 0.001) and intra-abdominal abscess (27.1% vs 7.3%, p = 0.025) were higher in patients presenting in 2020. Patients treated during the pandemic had higher rates of non-operative treatment (25.0% vs 7.3%, p = 0.044) requiring increased antibiotic use and image-guided percutaneous drain placement. They also had longer hospital length of stay by a median of 1 day (p = 0.001) and longer duration until symptom resolution by a median of 1 day (p = 0.004). Type of treatment was not a predictor of LOS (HR = 0.565, 95% CI = 0.357–0.894, p = 0.015) or duration until symptom resolution (HR = 0.630, 95% CI = 0.405–0.979, p = 0.040). Conclusion Patients treated for acute appendicitis at our children's hospital during the peak of the COVID-19 pandemic presented with more severe disease and experienced suboptimal outcomes compared to those who presented during the same time period in 2019. Level of Evidence III

Implications of the COVID-19 Pandemic for Pediatric Primary Care Practice in Europe

“…The health conditions which were most often unreported included diabetic ketoacidosis, hematology and oncology diseases, appendicitis, peritonitis, child abuse, severe bacterial infections such as urinary tract infection, meningitis, pneumonia and acute cardiac problems 13 . Similar data were reported in the US 20 and Israel 21 . A study involving 53 Italian diabetes centers revealed that COVID-19 has significantly worsened the presentation of type 1 diabetes in children 8 .…”

Is there an increased incidence of orchiectomy in pediatric patients with acute testicular torsion during COVID-19 pandemic?–A retrospective multicenter study

“…Several recent studies of acute appendicitis during COVID-19 pandemic clearly showed that staying at home due to public health safety orders negatively impacted children who developed appendicitis. During the COVID-19 pandemic increased rate of perforated appendicitis in pediatric patients, compared to pre-COVID-19 period, was reported in several published studies [ 11 , 13 , 14 , 15 ]. Also, the patients with perforated appendicitis had an increased rate of complications and length of hospital stay [ 13 ].…”

Surgeon-led 7-VINCut Antibiotic Stewardship Intervention Decreases Duration of Treatment and Carbapenem Use in a General Surgery Service

“…Some of the most frequent emergency surgical conditions showed reductions in their incidence up to 60% (62% for appendicitis, 39% for cholecystitis) [ 35 ], probably due to patients’ reluctance to attend hospital [ 35 ] or conservative treatments prescribed by primary care physicians [ 36 ]. In consequence, the disease seems to have been left to develop at home [ 35 , 36 ], and patients presented with more severe condition [ 36 , 37 , 38 ], making source control more difficult to achieve. Furthermore, some institutions recommended non-surgical management of cholecystitis or appendicitis [ 39 ] placing the emphasis on antibiotic treatment.…”

“…Boyle). In summary, patients experienced suboptimal outcomes with more complications and a longer length of stay in the ICU [ 35 ] or in-hospital [ 37 ], which increased the use of antibiotic treatments.…”