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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: Post Acceptance: October 28, 2017
doi: 10.1097/INF.0000000000001816
Original Studies: PDF Only


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 two successive interventions, an antimicrobial stewardship program (ASP) and a condition-specific clinical practice guideline (CPG), on antimicrobial utilization and patient outcomes in these patients.


The ASP at our institution was begun in March 2012. The CPG, which 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 three eras based on their exposure to: 1) neither intervention, 2) ASP only, or 3) both ASP and CPG. We compared measures of antibiotic utilization and clinical outcomes among the three eras.


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 IV 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.


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.

Corresponding Author: M. Cecilia Di Pentima, MD, MPH, Director, Pediatric Infectious Diseases Division, Atlantic Health System, Professor, Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, 100 Madison Ave., Morristown, NJ, Telephone: (973) 971-6329; Fax: (973) 290-717; E-mail:

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