Initial Antibiotics and Delayed Appendectomy for Acute Appendicitis
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Purpose
Several recent studies have examined the feasibility and benefits of nonoperative treatment of perforated appendicitis in children. One such study showed a trend toward longer operative times for patients randomized to immediate appendectomy, but no overall advantage. In another larger study, the costs of delayed appendectomy for perforated appendicitis were higher - in part related to readmissions in the interval (6-8 weeks). Nevertheless, these and other studies have demonstrated the safety of delaying appendectomy for perforated appendicitis.
Emergency appendectomy is a well-established approach, and postoperative recovery in children is fast. Nevertheless, from the onset of symptoms through the hospital stay and the postoperative recovery, appendicitis causes a disruption of a family's normal routine (absence from school and work) of up to 1-2 weeks. Because this is an unplanned operation, patients have to wait until an operating room becomes available, or elective operations have to be placed on hold to accommodate the emergency operation. Each year, more than 250 children undergo an appendectomy at HCH. This represents 250 episodes of emergency surgery, or about one emergency add-on operation per working day. If an initial trial of antibiotics is safe for the treatment of appendicitis, converting an emergency operation into an elective, scheduled outpatient procedure may reduce stress and disruption of routine for patients and their families - and may allow better operating room planning for health care professionals and hospitals.
The investigators hypothesize that initial antibiotic treatment of acute (non-perforated) appendicitis, followed by scheduled outpatient appendectomy, reduces the overall cost of treating the disease and results in greater patient and family satisfaction.
This pilot study aims to establish the safety and feasibility of treating acute appendicitis with intravenous antibiotics, followed by outpatient oral antibiotics. Patients and their families will be offered the possibility of initial nonoperative treatment and subsequent outpatient elective appendectomy in a nonrandomized, single arm study.
| Condition | Intervention |
|---|---|
|
Acute Appendicitis |
Drug: Piperacillin + Amoxicillin |
| Study Type: | Interventional |
| Study Design: | Endpoint Classification: Safety/Efficacy Study Intervention Model: Single Group Assignment Masking: Open Label Primary Purpose: Treatment |
| Official Title: | Initial Antibiotics and Delayed Appendectomy for Acute Appendicitis |
- Number of treatment failures [ Time Frame: Worsening of symptoms at 8 hours or failure of improvement at 18 hours of treatment ] [ Designated as safety issue: Yes ]If after a period of at least 8 hours (and 2 doses of intravenous antibiotics), the patient's symptoms worsen, or fail to subside within 18 hours, the patient will undergo an emergent/urgent appendectomy, and treatment will proceed as per standard-of-care (1 intraoperative dose of antibiotics, with or without postoperative antibiotics, progressive postoperative diet and discharge home once tolerating a regular diet). The patient will then be considered having failed nonoperative treatment.
- Cost-saving of initial nonoperative treatment for early appendicitis [ Time Frame: 1 year ] [ Designated as safety issue: No ]
Cost of nonoperative treatment will be calculated as follows: Hospitalization charges (# hospital days - observation) + costs of antibiotics (actual number of doses/days) + outpatient surgery hospital fee (operating room and PACU time) + additional costs associated with unanticipated events (e.g., Emergency room visits after initial discharge).
Control costs (contemporary data) will consider the following: Hospitalization charges (# hospital days) + intravenous antibiotics (price/dose x number of doses).
- Utility of initial nonoperative treatment of early appendicitis [ Time Frame: 1 year ] [ Designated as safety issue: No ]
Questionnaires given to parents and patients regarding their experience of initial nonoperative treatment and interval appendectomy will be analyzed, and compared with controls and with standard levels in the literature.
The Pediatric Quality of Life Scale-Version 4.0 (PedsQL) is a reliable and valid 23-item questionnaire that measures child health-related quality of life (QOL) in the preceding month. Items can be recoded from 100 to 0 on 25-point intervals and averaged to produce a total score (α=0.90). The total score is derived from items that assess the child's physical (e.g., problems with low energy or difficulty lifting something heavy), emotional (e.g., feeling afraid, angry, or scared), social (e.g., problems with getting teased or other children not wanting to be friends), and school functioning (e.g., problems paying attention in class or missing school). Higher scores indicate better QOL.
| Estimated Enrollment: | 65 |
| Study Start Date: | September 2012 |
| Estimated Primary Completion Date: | September 2013 (Final data collection date for primary outcome measure) |
| Arms | Assigned Interventions |
|---|---|
|
Experimental: Piperacillin + Amoxicillin
Piperacillin/Tazobactam (Zosyn®) 100 mg/kg, up to adult dose of 3 g, i.v. q 6 hours x 2 doses, followed by Ampicillin/Clavulanate (Augmentin®) 50 mg/kg/d p.o. in 3 divided doses for 1 week.
|
Drug: Piperacillin + Amoxicillin
Other Names:
|
Eligibility| Ages Eligible for Study: | 5 Years to 18 Years |
| Genders Eligible for Study: | Both |
| Accepts Healthy Volunteers: | No |
Inclusion Criteria:
- Maximum 48-hour-history of abdominal pain
- Diagnosis of acute appendicitis based on clinical, laboratory and/or radiologic criteria
Exclusion Criteria:
- Duration of symptoms > 48 hours
- Presence of an appendiceal abscess on imaging
- Clinical or laboratory suspicion of advanced appendicitis, peritonitis or perforation
- Significant comorbidities
- Inability or unwillingness to complete a 1-week course of oral antibiotics
- Allergy to penicillin
Contacts and Locations| United States, Rhode Island | |
| Hasbro Children's Hospital (Rhode Island Hospital) | Recruiting |
| Providence, Rhode Island, United States, 02905 | |
| Contact: Francois I Luks, MD, PhD 401-228-0556 Francois_Luks@brown.edu | |
| Contact: Debra Watson-Smith, RN 401-228-0559 dwsmith@usasurg.org | |
| Principal Investigator: Francois I Luks, MD, PhD | |
| Sub-Investigator: Christopher S Muratore, MD | |
| Principal Investigator: | Francois I. Luks, MD, PhD | Rhode Island Hospital |
More Information
Publications:
| Responsible Party: | Francois Luks, Francois I. Luks, MD, PhD, Rhode Island Hospital |
| ClinicalTrials.gov Identifier: | NCT01697059 History of Changes |
| Other Study ID Numbers: | RIH408212 |
| Study First Received: | September 24, 2012 |
| Last Updated: | October 3, 2012 |
| Health Authority: | United States: Institutional Review Board |
Keywords provided by Rhode Island Hospital:
|
appendicitis |
Additional relevant MeSH terms:
|
Appendicitis Acute Disease Gastroenteritis Gastrointestinal Diseases Digestive System Diseases Cecal Diseases Intestinal Diseases Disease Attributes Pathologic Processes |
Amoxicillin Anti-Bacterial Agents Piperacillin Amoxicillin-Potassium Clavulanate Combination Anti-Infective Agents Therapeutic Uses Pharmacologic Actions Enzyme Inhibitors Molecular Mechanisms of Pharmacological Action |
ClinicalTrials.gov processed this record on May 16, 2013