2019, Number 4
Impact of the use of post-surgical antibiotics in uncomplicated acute appendicitis
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ABSTRACT
Introduction: Acute appendicitis is the most common abdominal emergency in the world and the most common non-elective surgery, which is as an objective for the treatment of acute appendicitis (appendiceal perforation and abdominal sepsis), the use of subsequent antibiotics being a priority to surgery to prevent surgical site infections, however, currently, the use of antibiotics in patients operated on for appendicitis is not done indiscriminately and without a precise indication. Objective: To verify that the usefulness of antibiotics in the postoperative of patients with acute uncomplicated appendicitis are not necessary. Material and methods: An analytical, prospective and longitudinal study of patients with postoperative diagnosis of acute uncomplicated appendicitis was carried out during June 2017 to November 2018 at the "Dr. Aurelio Valdivieso" General Hospital, including 128 patients, divided into two groups in a simple random manner: 64 cases (without postoperative antibiotic) and 64 controls (with postoperative antibiotic: ceftriaxone or cefotaxime) evaluating postoperative infectious complications at 30 days and hospital stay, leukocytes and C-reactive protein on the 1st, 3rd and 10th day of surgery. Results: No significant differences were observed in both groups in the incidence of surgical site infection, where difference was appreciated was in the average hospital stay 2.16 vs 1.88 (p = 0.001). Conclusions: The use of antibiotic in the postoperative of uncomplicated acute appendicitis does not affect the incidence of surgical site infections, so its use should not be done systematically in all patients. The use of antibiotics in a prophylactic manner should be done as dictated by clinical practice guidelines, so that some variation in their use will cause an increase in the incidence of surgical site infection.INTRODUCTION
In Mexico, appendectomy is the most common emergency surgery, so the use of postoperative antibiotics is common.1 Surgical site infections in acute appendicitis occur in 5-10% of patients,2-5 so the use of antibiotics aims at preventing postoperative infectious complications.1 However, Corona and colleagues in a survey of general surgeons found an indiscriminate administration of antibiotics in appendectomized patients derived from lack of knowledge.1 According to a Cochrane survey in 2005, antibiotics in patients with uncomplicated appendicitis should be used only prophylactically. Their use in the post-surgical period is debated.6 Other postoperative studies conclude that in acute appendicitis antibiotic prophylaxis should be used, as well as in the postoperative of complicated cases.7-11 Retrospective studies support this view (Le and colleagues, Coakley and team, Ali and collaborators) and conclude that it increases hospital stay, hospital infections (urinary infections and pneumonia) and hospital costs.12-14 Concerning the Mexican guidelines, the Mexican Association of General Surgery (AMCG) does not make any recommendation regarding the use of antibiotics preoperatively, transoperatively or postoperatively, and the National Center for Technological Excellence in Health (Centro Nacional de Excelencia Tecnológica en Salud, CENETEC) agrees with antibiotic prophylaxis, but does not comment on its postoperative use.15,16 These distinctions are specified in the WSES (World Society of Emergency Surgery) Guidelines: antibiotic prophylaxis in acute appendicitis and postoperative complicated appendicitis but not in uncomplicated appendicitis.17
MATERIAL AND METHODS
An analytical, prospective, longitudinal study was done at the General Hospital "Dr. Aurelio Valdivieso" in Oaxaca, from June 2017 to November 2018. A population sample of 128 patients between 15 and 74 years of age with clinical symptoms of acute appendicitis of up to 48 hours of evolution was selected. Antibiotic prophylaxis with third generation cephalosporin or quinolone, in case of allergy to cephalosporins, was administered. Those that, according to the macroscopic characteristics of the appendix corresponded to uncomplicated appendicitis, were included in the study and patients with overweight and obesity (BMI greater than 27.5), with type 1 and 2 diabetes mellitus, autoimmune diseases, liver diseases, hyperthyroidism and hypothyroidism, acquired immunodeficiency, and cancer were excluded.
A 95% confidence level (alpha = 0.05). They all signed informed consent. They were divided into two groups in a simple randomized way, (Table 1). Group I, cases without postoperative antibiotics (31 men and 33 women), and control group II (27 men and 37 women) with postoperative administration of a third-generation cephalosporin or a quinolone (in case of history of allergies) for 24 hours after surgery and oral antibiotics for seven days. Leukocytes and C-reactive protein (CRP) were measured on admission, and on the third and tenth days after surgery (Figures 1 and 2). Only those patients with clinical signs of surgical site infection, pneumonia, urinary tract infection, or other remained hospitalized. Comparative analysis was carried out with IBM© SPSS© Statistic V23 software. χ2 test and Mann-Whitney U were done.
RESULTS
The number of surgical site infections for the group without postoperative antibiotics was 1 of 64, and none in the group with postoperative antibiotics. Deep incisional, organ/space infection, and pneumonia did not occur in either group. However, one case of urinary tract infection occurred in the group with postoperative antibiotics. The average hospital stay for the no antibiotic group was 1.88 days versus 2.16 days for the antibiotic group. We conducted χ2 and Mann-Whitney U to compare the group without postoperative antibiotics versus the group with postoperative antibiotics.
DISCUSSION
The incidence of surgical site infections in uncomplicated appendicitis is 4-10% as reported by different authors,7-10,12,13,18 is different from our study (1.6%). Those studies included overweight patients with BMI greater than 27.5), type 1 and 2 diabetes mellitus, autoimmune diseases, liver diseases, hyperthyroidism, hypothyroidism, acquired immunodeficiency, and cancer, while ours excluded patients with those diseases.
Surgical site infections after uncomplicated acute appendicitis are a known risk. Different approaches have been described to reduce it.3,19-22 The use of antibiotics has been evaluated since their introduction. In 2005, the Cochrane group carried out a systematic review of 45 prospective, randomized controlled studies. They concluded that antibiotics should be given prophylactically. Their use in the postoperative is debated. From this analysis, randomized clinical trials were conducted by Abdhullan et al., Hussain et al., Hughes et al., and Mui et al.,8-11 to evaluate their use, without antibiotic and with a postoperative antibiotic, and they concluded that antibiotics are not useful in patients with uncomplicated acute appendicitis to prevent surgical site infections. Such assertions are shared in our study. No difference in the incidence of wound infection was noted in patients whether they did or did not receive an antibiotic. In another study, Coakley et al.13 related the use of postoperative antibiotics in uncomplicated acute appendicitis to Clostridium difficile infection, urinary tract infections, and postoperative diarrhea. However, Hussain et al.9 observed no difference between the two groups, as in our study.
We did observe differences in hospital stay, which coincides with the report by Coakley and colleagues.13 These authors found differences between the leukocyte count of patients with postop antibiotics versus patients without them, which contrasts with our study where differences in leukocyte count and CRP were not found. Our study corroborates previous assertions. There is no difference in preventing surgical site infections in patients with uncomplicated acute appendicitis with or without antibiotics. The laboratory indicators (leukocytes and CRP) remain the same.
CONCLUSION
The incidence of surgical site infections in patients operated for uncomplicated acute appendicitis without the use of antibiotics is not increased. Antibiotics should be applied in properly selected patients with overweight or obesity (BMI greater than 27.5), type 1 and 2 diabetes mellitus, autoimmune diseases, liver diseases, hyperthyroidism or hypothyroidism, immunodeficiencies or cancer. The use of postoperative antibiotics in uncomplicated appendicitis increases hospital stay and does not increase comorbidities for other infections (pneumonia or urinary tract infection). We insist on the proper administration of antibiotic prophylaxis 30 minutes before the incision. These should be either ceftriaxone or cefotaxime, and ciprofloxacin in case of allergy. Variation in this behavior may result in increased surgical site infections.
REFERENCES
AFFILIATIONS
1 Division of Surgery, "Dr. Aurelio Valdivieso", General Hospital. Oaxaca, México.
2 División de Oncología Quirúrgica, High Specialty Regional Hospital. Oaxaca, México.
3 Division of Coloproctology, General Hospital of Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico.
Ethical considerations: Data privacy. In accordance with the protocols established in the authors\' workplace, they declare that they have followed the protocols on patient data privacy while preserving their anonymity. The informed consent of the patient referred to in the article is in the possession of the author.
Funding: No financial support was received for this work.
Conflict of interest: The authors declare that there was no conflict of interest in carrying out this work.
CORRESPONDENCE
Dr. Jorge Hernández Cortez. E-mail: dr.jorge_hdz@outlook.comReceived: 06/03/2019. Accepted: 13/08/2019