Perforated Appendicitis in Children: Use of Metronidazole for the Reduction of Septic Complications

Abstract

Fifty-four consecutive children with performed appendicitis were treated with intravenous and rectal metronidazole combined with another antimicrobial agent. Positive cultures were obtained from peritoneal swabs from all children except from four patients who produced no growth on culture. Mixed growth of aerobic and anaerobic organisms were isolated from 44 patients. Four patients had pure growth of aerobes and two had pure growth of anaerobes. Results were compared with 49 cases of performed appendicitis treated with a combination of Gentamicin and Cephradine and who did not receive metronidazole. The overall incidence of complications was reduced from 44.9% to 14.8%. A significant reduction in the incidence of wound infection (p less 0.01) and pelvic abscess (p less than 0.025) was observed in the metronidazole treated group. The period of hospitalization averaged 13.8 days in patients treated with metronidazole as compare to 18.2 days in those treated without metronidazole.

Acute appendicitis is characterized by a uniform and highly selective pattern of inflammatory gene expression

“…Although it is commonly held that obstruction of the appendiceal lumen and subsequent tissue hypoxia and bacterial overgrowth are the precipitating factors of this disease,3,4 there is scant evidence to support or refute this hypothesis. Although obstruction of the intestinal lumen by a fecalith is a common finding in AA, large studies suggest that a fecalith is not present in as many as 50 % of cases 5.…”

Tobramycin-clindamycin Versus Cephalothin-cephalexin in the Treatment of Appendicular Peritonitis

“…In comparable series reported during the last 10 years the rate of complications has ranged from 10 % to 480/0 (1,5,8,14,16,17,22) or has been nil (7). Our high rate of complications, 320/0, may partly be explained by de- laycd administration of antibioties.…”

“…Thus, already more than 80 years ago the pathogenetic interaction between anaerobes and aerobs had been c1early implicated in appendicular peritonitis (3,15,21). In recent years interest in the role of anaerobes in the complications on intestinal surgery has been reneved and swdied both clinically and experimentally (4,7,10,11,12,13,14,18). Because there is still some comroversy over which antimicrobials are most effective in the treatment of appendicular peritonitis ( compared the efficacy of the combination tobramycin-clindamycin with that of cephalothin followed by cephalexin in a prospective study.…”

Die antibiotische Behandlung der Appendicitis perforata im Kindesalter - Eine prospektive Studie

“…Die Effektivität von Metronidazol bei anaeroben Infektionen ist nicht nur durch unsere Studie, sondern auch durch zahlreiche andere Publikationen belegt (7,8,19). Die Vorteile liegen vor allem darin, daß sowohl durch die intravenöse als auch durch die rektale Verabreichung ausreichende Gewebsspiegel erreicht werden können (8).…”

“…Den Fortschritten der Intensivmedizin und dem Einsatz geeigneter Antibiotika ist es zu verdanken, daß heute nahezu kein Kind mehr an einer Appendicitis perforata stirbt. Postoperative Komplikationen, insbesondere durch Wundabszesse, intraperitoneale Abszesse sind dagegen häufig, und die Morbidität nach Perforation einer Appendizitis wurde in der Literatur mit Raten zwischen 30% und 80% angegeben (4,7,13,19,20,22). Trotz der Anwendung verschiedener lokaler Maßnahmen wie Bauchhöhlenspülungen oder Drainagen schien gerade die Rate postoperativer Wundinfektionen und intraabdomineller Abszesse unbeeinflußbar zu bleiben, so daß einige Autoren eine grundsätzlich offene Wundbehandlung mit sekundärer Faszienhautnaht oder bei Fehlen von klinischen Sepsiszeichen sogar den völligen Verzicht auf eine antibiotische Behandlung empfahlen (1,9,12,21).…”