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Improvements in Antimicrobial Prescribing and Outcomes in Pediatric Complicated Appendicitis

Willis, Zachary, I., MD*; Duggan, Eileen, M., MD, MPH; Gillon, Jessica, PharmD, BCPS; Blakely, Martin, L., MD, MS§; Di Pentima, M., Cecilia, MD, MPH*

The Pediatric Infectious Disease Journal: May 2018 - Volume 37 - Issue 5 - p 429–435
doi: 10.1097/INF.0000000000001816
Original Studies

Background: Complicated appendicitis, characterized by perforation and/or peritonitis, is common in children, and late infectious complications are frequent. The best antibiotic treatment approach is unknown, resulting in substantial variation in care. We evaluated the effects of 2 successive interventions, an antimicrobial stewardship program (ASP) and a condition-specific clinical practice guideline (CPG), on antimicrobial utilization and patient outcomes in these patients.

Methods: The ASP at our institution was begun in March 2012. The CPG, a standardized antibiotic treatment, was implemented in July 2013. We reviewed every case of complicated appendicitis managed with early appendectomy between January 2011 and October 2014. Patients were thus divided into 3 eras based on their exposure to the following: (1) neither intervention, (2) ASP only or (3) both ASP and CPG. We compared measures of antibiotic utilization and clinical outcomes among the 3 eras.

Results: A total of 313 patients were included in the study: 91 exposed to neither intervention; 100 exposed to only the ASP; and 122 exposed to both interventions. With ASP implementation, there were declines in the use of unnecessarily broad or toxic antibiotic regimens. With CPG implementation, there was a decrease in total antibiotic utilization and discharges with intravenous antibiotics. Compliance with CPG-recommended antibiotics exceeded 90%. There was no significant change in overall adverse events; there was a decline in the incidence of surgical-site infections in patients exposed to both interventions.

Conclusions: Complicated appendicitis is an important target for antimicrobial stewardship and quality improvement efforts. A condition-specific CPG can improve both antimicrobial utilization and clinical outcomes.

From the *Department of Pediatrics, Vanderbilt University School of Medicine

Department of Surgery, Vanderbilt University School of Medicine

Department of Pharmacy, Monroe Carell Jr. Children’s Hospital at Vanderbilt

§Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.

Accepted for publication August 27, 2017.

The authors have no funding or conflicts of interest to disclose.

Address for correspondence: M. Cecilia Di Pentima, MD, MPH, Sidney Kimmel Medical College at Thomas Jefferson University, 100 Madison Avenue, Morristown, NJ. E-mail:

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