A role for conservative antibiotic treatment in early appendicitis in children. Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study. A double-blind controlled trial of metronidazole suppositories in children undergoing appendicectomy. [Antibiotic treatment of perforated appendicitis in childhood--a prospective study]. Subcuticular Skin Closure as a Standard Approach to Emergency Appendectomy in Children: Prospective Clinical Trial Laparoscopy in children with complicated appendicitis. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. Laparoscopic versus conventional appendectomy in children Non-operative management of early, acute appendicitis in children: is it safe and effective? Prophylactic antibiotics in uncomplicated appendicitis during childhood--a prospective randomised study. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial) Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial Discharge planning for children with perforated appendicitis. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. Study of appendicitis in children treated with four different antibiotic regimens.
PURPOSE To evaluate whether antibiotics without surgery is sufficient treatment for children with clinical ly and ultrasonographically suspected acute appendicitis ( AA ) . METHOD Children with clinical , laboratory and radiological findings suspicious for AA were evaluated prospect ively . Patients with mild clinical signs , without peritonitis were considered for IV followed by oral antibiotics without surgery . RESULTS From 1 November 2013 through 30 June 2014 , 45 children were diagnosed with early , acute appendicitis . Ages ranged from 4 to 15 years ( mean 9.3 ) and 32 ( 75 % ) were boys . All had routine , clinical laboratory and ultrasound workup . Forty-two improved with antibiotic treatment and were discharged home within 3 - 5 days , without surgery . Three of them were operated on within 24 hours , another two underwent appendectomy for recurrent appendicitis : one at 2 weeks and the other 2 months after discharge . There was no more recurrent appendicitis in 6 - 14-month follow-up . CONCLUSION Our series of patients with AA treated with antibiotics only are a product of the observation that some children improve with antibiotics alone at a stage in which surgery is still debatable . These results ( 89 % success rate ) support the conservative approach in cases of early appendicitis , without increased morbidity in failed cases BACKGROUND Initial antibiotic treatment for acute appendicitis has been shown to be safe in adults ; so far , not much is known about the safety and efficacy of this treatment in children . The aims of this study were to investigate the feasibility of a r and omized controlled trial ( RCT ) evaluating initial antibiotic treatment for acute appendectomy in children with acute simple appendicitis and to evaluate the safety of this approach . METHODS In a multicenter , prospect i ve cohort study patients aged 7 - 17 years with a radiologically confirmed simple appendicitis were eligible .  Intravenous antibiotics ( amoxicillin/clavulanic acid 250/25 mg/kg 4 times daily ; maximum 6,000/600 mg/d and gentamicin 7 mg/kg once daily ) were administered for 48 - 72 hours . Clinical reevaluation every 6 hours , daily blood sample s , and  ultrasound follow-up  after 48 hours was performed . In case of improvement after 48 hours , oral antibiotics were given for a total of 7 days . At any time , in case of clinical deterioration or non-improvement after 72 hours , an appendectomy could be performed . Follow-up continued until 8 weeks after discharge . Adverse events were defined as major complications of antibiotic treatment , such as allergic reactions , perforated appendicitis , and recurrent appendicitis . RESULTS Of 44 eligible patients , 25 participated ( inclusion rate , 57 % ; 95 % CI , 42%-70 % ) . Delayed appendectomy was performed in 2 , and the other 23 were without symptoms at the 8 weeks follow-up . Minor complications occurred in three patients . None of the patients suffered from an adverse event or a recurrent appendicitis . CONCLUSION Our study shows that an RCT comparing initial antibiotic treatment strategy with urgent appendectomy is feasible in children ; the intervention seems to be safe A total of 133 children , aged 16 months to 15 years ( mean 6.7 years ) , with presumptive acute appendicitis , was included in a double-blind , placebo-controlled trial of the short-term ( 72 hour ) use of metronidazole suppositories as prophylaxis against post-operative infection . There was no significant difference in the incidence or severity of wound infection or post-operative intra-abdominal sepsis between the metronidazole-treated and placebo groups . It is suggested that intra-rectal metronidazole , when used exclusively , is not sufficient for effective prophylaxis for appendicitis in childhood A prospect i ve r and omised study ( I ) was carried out on 130 children undergoing laparotomy for perforated appendicitis . The present study evaluates the therapeutic effectiveness of different antibiotic regimens in modifying the rate of post-operative complications ( intraabdominal abscess , ileus , wound infiltration or abscess ) . During the first year of this study two treatment groups were used . Group A consisted of 29 children treated with Sulfometrol/Trimethoprim ; the rate of postoperative complications was 44.8 % . Group B consisted of 36 children treated with mezlocillin , the rate of complications being 13.8 % . However , the same treatment with mezlocillin during the second year of the prospect i ve study showed an increase of this rte to 39 % ( 28 children -- group C ) . The final group of 37 children was treated during the second year with mezlocillin and metronidazole ( group D ) . The postoperative rate of complications was 10.8 % . A retrospective analysis of further 80 children ( study II ) with perforated appendicitis treated with mezlocillin and metronidazole  showed a consistent low rate of postoperative complications at 10.2 % . In 6.8 % of children studied , an operative intervention was necessary ( four cases of ileus , four wound abscesses ) . The mean postoperative hospitalisation period decreased from 22.7 days in group A to 15.2 days in group D and finally to 14 days in study II . The present study shows that an effective and persistent attenuation of the rate of postoperative complications after perforated appendicitis in children depends on an early onset of therapy and on the appropriate choice of antibiotic drugs that are effective against aerobic and anaerobic microorganisms Abstract . We evaluated the morbidity associated with primary closure by interrupted subcuticular absorbable sutures  following emergency appendectomy .  In a prospect i ve clinical trial over a 12-month period , 216 children who underwent emergency appendectomy had skin closure using subcuticular interrupted absorbable polyglactin 4 - 0 sutures . Preoperative prophylactic antibiotics consisting of metronidazole alone or in combination with gentamicin were used in patients with suspected phlegmonous appendicitis ; a combination of metronidazole , gentamicin , and ampicillin was used when perforation of the appendix was suspected . Postoperatively , in patients with phlegmonous appendicitis  metronidazole was given for 24 hours , whereas in those with peritonitis the triple antibiotics were continued for 7 to 10 days . All patients were assessed for complications result ing from the technique of wound closure . No intraabdominal abscesses or serious complications were recorded . The overall incidence of wound infection was 1.8 % . Among children with a perforated appendix the rate of superficial wound infection was 5.7 % . There was no difference in the rate of wound infection between patients who received metronidazole alone or metronidazole plus gentamicin preoperatively . All the patients and their families were satisfied with the cosmetic results and with the fact that removal of skin sutures was unnecessary . We conclude that the use of prophylactic antibiotics permits st and ard skin closure by interrupted absorbable subcuticular suture BACKGROUND / PURPOSE Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children . The role of laparoscopy in complicated acute appendicitis is more controversial . The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis . METHODS A total of 102 children with suspected acute appendicitis were selected r and omly to undergo either a laparoscopic or an open appendectomy . The outcomes of 25 children with complicated appendicitis , 13 in the laparoscopic group and 12 in the open appendectomy group , were analyzed . Children , their parents , and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation . All 25 children completed a 30-day follow-up . RESULTS There were no differences in terms of patients ' age , sex , weight , height , and appendiceal histology between the 2 groups . All laparoscopic procedures were completed without conversion . The mean ( + /-SD ) operating time was 63 ( + /-31 ) minutes in the laparoscopic group and 37 ( + /-18 ) minutes in the open appendectomy group ( mean difference 26 minutes , 95 % CI 5 to 47 minutes , P = .02 ) . There were 2 major complications in the laparoscopic group in children with appendiceal masses . One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation . Another child had a pelvic abscess that resolved with antibiotic treatment . Superficial wound infections were encountered in 2 patients in the open appendectomy group . CONCLUSIONS Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis . Good surgical judgement is necessary in patients with an established appendiceal abscess INTRODUCTION In a previous prospect i ve r and omized trial , we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient , cost-effective treatment for children with perforated appendicitis . In this study , we evaluated the safety of discharging patients to complete an oral course of antibiotics . METHODS Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study . Perforation was defined as a hole in the appendix or fecalith in the abdomen . Patients were r and omized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days ( intravenous [ IV ] arm ) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet ( IV/PO arm ) to complete 7 days . RESULTS One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis . On presentation , there were no differences in age , weight , sex distribution , days of symptoms , maximum temperature , or leukocyte count between the 2 groups . There was no difference in the postoperative abscess rate between the two treatment groups . Discharge was possible before day 5 in 42 % of the patients in the IV/PO arm . CONCLUSIONS When patients are able to tolerate a regular diet , completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation Over a period of 6 months , 48 children who underwent conventional appendectomy ( CA ) were compared to 34 children who had laparoscopic appendectomy ( LA ) for acute and recurrent subacute appendicitis . Their ages ranged from 4 to 12 years ( mean 8) .  LA took significantly longer , 76 min , versus 50 min for CA . Less than 2 days ’ hospitalization was required in 95 % of LA cases and 45 % of CA cases . Time to return to normal activity averaged 7 days for LA and 12 days for CA ( P < 0.001 ) . Wound complications were fewer and the cosmetic appearance was most satisfactory in LA patients . LA is a safe operation that has the advantage of being exploratory , with shorter hospitalization time , early ambulation , and superior cosmetic results PURPOSE The purpose of this study was to determine if early , acute appendicitis in children can be safely and effectively managed with antibiotics alone . METHODS A retrospective review was performed of children ( < 18 yrs ) treated non-operatively ( NOM ) for early , acute appendicitis since May 2012 . These were compared to patients treated with appendectomy between January 2011 and October 2011 ( OM ) . Inclusion criteria included : ( a ) symptoms < 48 h , ( b ) localized peritonitis , and ( c ) ultrasound findings consistent with early , acute appendicitis . RESULTS Twelve patients ( 66 % female , mean age 12.2,SD=4.2 yrs ) were treated non-operatively , while 12 ( 50 % female , mean age 12.5,SD=3.2 yrs ) were treated operatively . Two NOM children ( 16.7 % ) required initial appendectomy . One patient developed recurrent appendicitis requiring appendectomy 7 months post-discharge . Four other NOM patients returned with symptoms but did not require admission or surgery . Two OM patients ( 8.3 % ) had hospital visits and admissions related to surgical site infections . Mean length of stay ( LOS ) for the first visit was 1.5 days ( SD=1.0d ) ( NOM ) vs. 1.3 days ( SD=0.5d ) ( OM ) ( p=0.61 ) . Including first and subsequent admissions , mean LOS was 1.8 days ( SD=1.1d ) ( NOM ) vs. 1.7 days ( SD=1.5d ) ( OM ) ( p=0.97 ) . CONCLUSION Early acute appendicitis in appropriately selected children can be successfully treated non-operatively . R and omized trials with longer follow-up are required 544 children operated upon for uncomplicated appendicitis were r and omised into three groups . Group I received no antibiotics , patients in Group II were administered one single pre-operative dose of metronidazole ( 10 mg/kg ) and patients in Group III received both both metronidazole ( 20 mg/kg ) and cefuroxime ( 50 mg/kg ) in a single preoperative dose . The rate of infectious complications in Group I was 6.3 % but only 2.1 and 2.3 in Groups II and III , respectively . Among patients with a normal appendix or patients with simple appendicitis there was no difference in the rate of post-operative infections between the three different groups . However , in patients with gangrenous appendicitis the rate of postoperative infections was significantly lower in the two groups who received preoperative antibiotics ( 1.8 % and 3.0 % respectively ) than in the group receiving no prophylactic antibiotics ( infection rate 14 % ) . It is concluded that a single preoperative dose of metronidazole significantly decreases the rate of postoperative infectious complications in children with appendicitis . No further improvement could be demonstrated if cefuroxime against aerobic organisms was added INTRODUCTION Appendicitis is the most common emergency condition in children . Historically , a 3-drug regimen consisting of ampicillin , gentamicin , and clindamycin ( AGC ) has been used postoperatively for perforated appendicitis . A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole ( CM ) to be a more simple and cost-effective antibiotic strategy . Therefore , we performed a prospect i ve , r and omized trial to compare efficacy and cost-effectiveness of these 2 regimens . METHODS After internal review board approval ( IRB no. 04 12 - 149 ) , children found to have perforated appendicitis at appendectomy were r and omized to either once daily dosing of CM ( 2 total doses per day ) or st and ard dosing of AGC ( 11 total doses per day ) . Perforation was defined as an identifiable hole in the appendix . The operative approach ( laparoscopic ) , length of antibiotic use , and criteria for discharge were st and ardized for the groups . Based on our retrospective analysis using length of postoperative hospitalization as a primary end point , a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82 . RESULTS One hundred patients underwent laparoscopic appendectomy for perforated appendicitis . On presentation , there were no differences in sex distribution , days of symptoms , temperature , or leukocyte count . There was no difference in abscess rate or wound infections between groups . The CM group result ed in significantly less antibiotic charges then the AGC group . CONCLUSIONS Once daily dosing with the 2-drug regimen ( CM ) offers a more efficient , cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen Background Although the st and ard treatment of acute appendicitis ( AA ) consists of an early appendectomy , there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA . However , the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial . Methods / design The APPAC trial is a r and omized prospect i ve controlled , open label , non-inferiority multicenter trial design ed to compare antibiotic therapy ( ertapenem ) with emergency appendectomy in the treatment of uncomplicated AA . The primary endpoint of the study is the success of the r and omized treatment . In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year ( treatment efficacy ) . Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100 % . Secondary endpoints are post-intervention complications , overall morbidity and mortality , the length of hospital stay and sick leave , treatment costs and pain scores ( VAS , visual analoque scale ) . A maximum of 610 adult patients ( aged 18–60 years ) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and r and omized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem ( 1 g per day ) for three days continued by oral levofloxacin ( 500 mg per day ) plus metronidazole ( 1.5 g per day ) for seven days . Follow-up by a telephone interview will be at 1 week , 2 months and 1 , 3 , 5 and 10 years ; the primary and secondary endpoints of the trial will be evaluated at each time point . Discussion The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75–85 % of patients with uncomplicated AA can be treated with effective antibiotic  therapy avoiding unnecessary appendectomies and the related operative morbidity , also result ing in major cost savings . Trial registration Clinical OBJECTIVE The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children . METHODS A pilot r and omized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children . Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were r and omized either to treatment with antibiotics or to surgery . Follow-up was for 1 year . RESULTS Fifty patients were enrolled ; 26 were r and omized to surgery and 24 to nonoperative treatment with  antibiotics . All children in the surgery group had histopathologically confirmed acute appendicitis , and there were no significant complications in this group . Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis . Another 6 patients have had an appendectomy due to recurrent abdominal pain ( n = 5 ) or parental wish ( n = 1 ) during the follow-up period ; none of these 6 patients had evidence of appendicitis on histopathological examination . CONCLUSIONS Twenty-two of 24 patients ( 92 % ) treated with antibiotics had initial resolution of symptoms . Of these 22 , only 1 patient ( 5 % ) had recurrence of acute appendicitis during follow-up . Overall , 62 % of patients have not had an appendectomy during the follow-up period . This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted Importance Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis , but long-term outcomes are not known . Objective To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis . Design , Setting , and Participants Five-year observational follow-up of patients in the Appendicitis Acuta ( APPAC ) multicenter r and omized clinical trial comparing appendectomy with antibiotic therapy , in which 530 patients aged 18 to 60 years with computed tomography – confirmed uncomplicated acute appendicitis were r and omized to undergo an appendectomy ( n = 273 ) or receive antibiotic therapy ( n = 257 ) . The initial trial was conducted from November 2009 to June 2012 in Finl and ; last follow-up was September 6 , 2017 . This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone . Interventions Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole . Main Outcomes and Measures In this analysis , prespecified secondary end points reported at 5-year follow-up included late ( after 1 year ) appendicitis recurrence after antibiotic treatment , complications , length of hospital stay , and sick leave . Results Of the 530 patients ( 201 women ; 329 men ) enrolled in the trial , 273 patients ( median age , 35 years [ IQR , 27 - 46 ] ) were r and omized to undergo appendectomy , and 257 ( median age , 33 years , [ IQR , 26 - 47 ] ) were r and omized to receive antibiotic therapy . In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year ( 27.3 % [ 95 % CI , 22.0%-33.2 % ] ; 70/256 ) , 30 additional antibiotic-treated patients ( 16.1 % [ 95 % CI , 11.2%-22.2 % ] ; 30/186 ) underwent appendectomy between 1 and 5 years . The cumulative incidence of appendicitis recurrence was 34.0 % ( 95 % CI , 28.2%-40.1 % ; 87/256 ) at 2 years , 35.2 % ( 95 % CI , 29.3%-41.4 % ; 90/256 ) at 3 years , 37.1 % ( 95 % CI , 31.2%-43.3 % ; 95/256 ) at 4 years , and 39.1 % ( 95 % CI , 33.1%-45.3 % ; 100/256 ) at 5 years . Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis , 76 had uncomplicated appendicitis , 2 had complicated appendicitis , and 7 did not have appendicitis . At 5 years , the overall complication rate ( surgical site infections , incisional hernias , abdominal pain , and obstructive symptoms ) was 24.4 % ( 95 % CI , 19.2%-30.3 % ) ( n = 60/246 ) in the appendectomy group and 6.5 % ( 95 % CI , 3.8%-10.4 % ) ( n = 16/246 ) in antibiotic group ( P < .001 ) , which calculates to 17.9 percentage points ( 95 % CI , 11.7 - 24.1 ) higher after surgery . There was no difference between groups for length of hospital stay , but there was a significant difference in sick leave ( 11 days more for the appendectomy group ) . Conclusions and Relevance Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis , the likelihood of late recurrence within 5 years was 39.1 % . This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis . Trial Registration Clinical Trials.gov Identifier : Optimal management of children with perforated appendicitis remains a controversial clinical problem . Until very recently , the criteria for hospital discharge on our surgical service included the absence of fever and leukocytosis for a period of 48 hours following completion of antimicrobial therapy , uncomplicated wound healing , a normal rectal examination , and unimpaired gastrointestinal function . With the introduction of cost-containment programs , the necessity for the period of inpatient observation following cessation of antibiotics was question ed . The records of 87 consecutive children with perforated appendicitis were analyzed prospect ively in order to determine if our discharge policies were medically sound and cost-effective . Seventy-five patients ( 86 % ) recovered uneventfully while 12 children required prolonged hospitalization for management of various postoperative complications . The 12 patients who developed complications were all identifiable early in the postoperative period because of persistent fever , leukocytosis , and elevated b and counts . Of the 75 children who recovered uneventfully , all met st and ard discharge criteria on the final day of antibiotic therapy with the exception of completing the m and atory 48-hour period of inpatient observation . These children were maintained in the hospital a total of 142 additional days following discontinuation of antibiotics . The average cost per patient day for children with perforated appendicitis during the study period was $ 506.32 , which represented unnecessary hospital charges of $ 71,897.44 . It was concluded that inpatient observation following cessation of antibiotic therapy in children who experience an uneventful recovery from perforated appendicitis is neither necessary nor cost-effective . ( ABSTRACT TRUNCATED AT 250 WORDS HYPOTHESIS For children with perforated appendicitis , the use of a prolonged course of intravenous ( i.v . ) antibiotics is equivalent to a short course of i.v . antibiotics followed by sequential conversion to oral ( PO ) antibiotics . DESIGN Prospect i ve , r and omized , clinical trial . SETTING Multicenter study in tertiary children 's hospitals . PATIENTS Children ( aged 5 - 18 years ) with perforated appendicitis found at laparotomy . INTERVENTION Children were r and omized after appendectomy either to a 10-day course of a combination of i.v . ampicillin , gentamicin sulfate , and clindamycin ( n = 10 ) ; or to a short course of a combination of i.v . ampicillin , gentamicin , and clindamycin , followed by conversion to a combination of p.o . amoxicillin and clavulanate potassium plus metronidazole ( n = 16 ) . MAIN OUTCOME MEASURES The primary outcome measure was clinical success , which was rated as complete , partial , or failure . Secondary outcome measures included return of oral intake , duration of fever , return of normal white blood cell count , and patient charges . Treatment equivalence was determined using confidence interval analysis . RESULTS We found treatment equivalence between the i.v . and i.v./p.o . groups , with 6 ( 60 % ) complete and 4 ( 40 % ) partial successes for the 10 patients in the i.v . group and 15 ( 94 % ) complete and 1 ( 6 % ) partial successes for the 16 patients in the i.v./p.o . group ( P < or = .05 ) . There was no difference in return of oral intake , duration of fever , or return of normal white blood cell count between the groups . Conversion to oral therapy results in savings of approximately $ 1500 per case . CONCLUSION There is treatment equivalence between prolonged i.v . therapy and i.v . therapy followed by conversion to oral antibiotic therapy in children with perforated appendicitis This is a prospect i ve and r and omized study of 100 patients with acute appendicitis who were less than 10 years old , in which four different antibiotic regimens commonly in use against gram-negative and anaerobic bacteria were compared in terms of postoperative septic complications . The antibiotics were begun immediately preoperatively and continued for five days . Ten percent of the patients developed infection complications , with 4 % requiring further surgery . The best results were obtained with cefoxitin ( 4 % of infection ) ,  metronidazole plus amikacin and latamoxef ( 8 % ) , while the regimen of clindamycin plus amikacin was associated with the greatest number of complications ( 20 % ) . On analyzing the main microbiologic findings of the study , we conclude that some sort of antibiotic treatment is indicated in all types of appendicitis , due to the occult presence of bacteria in the peritoneal cavity , even without clinical evidence of gangrene or perforation . Further , we emphasize the significance of Streptococcus faecalis as being responsible , along with Escherichia coli and Bacteroides fragilis , for serious postoperative complications
There was no consistency among the protocol s regarding length of antibiotic use , discharge criteria , or use of home antibiotics following discharge .
Limiting duration of antibiotic use to3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection .
In the absence of higher-level evidence , shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe
The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated .