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Acute appendicitis is a common surgical emergency in children. Non-perforated appendicitis patients do not require antibiotics after appendectomy. Although guidelines and recommendations exist to decrease post-operative antibiotic mis-use after appendectomy, surgeons continue to prescribe unwarranted antibiotics.
The aim of this study is to determine if an Antimicrobial Stewardship Program in Pediatric Surgery will decrease the use of un-warranted antibiotics.
Many surgeons continue to treat non-perforated or "borderline perforated" appendicitis with postoperative antibiotics despite an evidence-based definition of perforation (in the pediatric surgical literature) and many guidelines and recommendations that specify that no postoperative antibiotics are required. Children with perforated appendicitis are also often treated with longer-than-necessary courses of antibiotics. Although surgeons may feel that they only prescribe additional doses on occasion, evidence suggests that this behavior occurs in over 50% of children with non-perforated appendicitis.
These additional doses contribute to a longer length of stay, excess costs to the health care system, and disrupt patient flow. Additionally, the patients are exposed to more antibiotics and their potential for adverse effects (such as incorrect dose, incorrect medication, allergic reaction, antimicrobial resistance or c difficile infection).
Antimicrobial stewardship programs have been successful in pediatrics and adult general surgery in curbing unwarranted antibiotic use, but have never been evaluated in pediatric general surgery.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| NO Antimicrobial Stewardship Program | Prospective cohort of children who undergo appendectomy for acute appendicitis (perforated and non-perforated) BEFORE the implementation of the Antimicrobial Stewardship Program. | ||
| WITH Antimicrobial Stewardship Program | Prospective cohort of children who undergo appendectomy for acute appendicitis (perforated and non-perforated) WITH the implementation of the Antimicrobial Stewardship Program. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Antimicrobial Stewardship Program | Other | Twice weekly meeting with Infectious Disease and Pediatric Surgery team members to audit antibiotics prescribed and suggest role for discontinuation. |
| Measure | Description | Time Frame |
|---|---|---|
| Compliance with American Pediatric Surgical Association recommendations for postoperative antibiotics for appendicitis | Includes both intravenous and oral antibiotics prescribed, both during the time frame from admission until discharge, in addition to any prescription given for home, oral antibiotics. Measured as yes/no | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| Measure | Description | Time Frame |
|---|---|---|
| Postoperative intravenous antibiotics for non-perforated appendicitis | measured as number of days (ie number of doses divided by number of doses-per-day) | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| Postoperative oral antibiotics for non-perforated appendicitis |
| Measure | Description | Time Frame |
|---|---|---|
| Postoperative fever | Rectal temperature above 100.4ºF (38ºC), measured as yes/no and on what postoperative day Oral temperature above 100ºF (37.8ºC) Axillary (armpit) temperature above 99ºF (37.2ºC) Ear (tympanic membrane) temperature above 100.4ºF (38ºC) in rectal mode or 99.5ºF (37.5ºC) in oral mode Forehead (temporal artery) temperature above 100.4ºF (38ºC) | Length of admission |
Inclusion Criteria:
Exclusion Criteria:
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The study population is the pediatric surgeons at our institution who will have their antibiotic prescribing audited.
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| Name | Affiliation | Role |
|---|---|---|
| Anna Shawyer, MS, MSc | Alberta Children's Hospital | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 19040944 | Result | St Peter SD, Sharp SW, Holcomb GW 3rd, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg. 2008 Dec;43(12):2242-5. doi: 10.1016/j.jpedsurg.2008.08.051. | |
| 21034941 | Result | Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ; 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee. Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg. 2010 Nov;45(11):2181-5. doi: 10.1016/j.jpedsurg.2010.06.038. |
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| ID | Term |
|---|---|
| D001064 | Appendicitis |
| ID | Term |
|---|---|
| D059413 | Intraabdominal Infections |
| D007239 | Infections |
| D005759 | Gastroenteritis |
| D005767 | Gastrointestinal Diseases |
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measured as number of days (ie number of doses divided by number of doses-per-day) |
| From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| Readmission within 30 days | Need for readmission within 30 days of discharge, measured as yes/no | Within 30 days of discharge |
| Peripherally inserted intravenous catheter (PICC) | Need for PICC insertion for long term antibiotics, intravenous fluids or parenteral nutrition, measured as yes/no | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| Drain insertion | Need for a drain insertion (by interventional radiology) for postoperative abscess, measured as yes/no | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| Re-operation | Need for re-operation on the same admission, measured as yes/no | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| Length of Stay | Measured in days (from date of admission until date of discharge) | Length of admission |
| Adverse reaction to antibiotic | Measured as yes/no in addition to description of reaction (eg hives, shortness of breath) | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| Wrong medication/Wrong dose | Measured as yes/no in addition to description of problem (wrong dose, wrong medication) | From date of admission until date of first follow-up visit, typically within 4-6 weeks of discharge |
| C difficile infection | Measured as yes/no based on stool assay | From date of admission until first follow-up visit, typically within 4-6 weeks of discharge |
| 23932828 | Result | Srigley JA, Brooks A, Sung M, Yamamura D, Haider S, Mertz D. Inappropriate use of antibiotics and Clostridium difficile infection. Am J Infect Control. 2013 Nov;41(11):1116-8. doi: 10.1016/j.ajic.2013.04.017. Epub 2013 Aug 7. |
| 21292089 | Result | Rangel SJ, Fung M, Graham DA, Ma L, Nelson CP, Sandora TJ. Recent trends in the use of antibiotic prophylaxis in pediatric surgery. J Pediatr Surg. 2011 Feb;46(2):366-71. doi: 10.1016/j.jpedsurg.2010.11.016. |
| 20133327 | Result | Ghaleb MA, Barber N, Franklin BD, Wong IC. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child. 2010 Feb;95(2):113-8. doi: 10.1136/adc.2009.158485. Epub 2010 Feb 4. |
| D004066 |
| Digestive System Diseases |
| D002429 | Cecal Diseases |
| D007410 | Intestinal Diseases |