Narrow Spectrum Antibiotics as Effective as Broad Spectrum in Pediatric Patients with Appendicitis

Antibiotics for Appendicitis: Is Broader Better?

Deborah Lehman, MD reviewing Kronman MP et al. Pediatrics 2016 Jul.

Extended-spectrum antibiotics offer no advantage over narrower-spectrum antibiotics when treating appendicitis.

Acute appendicitis, a common pediatric condition requiring hospitalization, sometimes requires an extended course of antibiotics for complicated disease. Guidelines for antibiotic selection vary, and some recommend broad-spectrum antibiotics to cover resistant gram-negative organisms, includingPseudomonas aeruginosa.

In a retrospective cohort study, investigators compared failure rates of extended-spectrum (e.g., piperacillin-tazobactam) versus narrow-spectrum (e.g., cefoxitin) antibiotic therapy in nearly 25,000 children aged 3–18 years hospitalized for complicated or uncomplicated appendicitis at 23 U.S. children’s hospitals. Treatment failure was defined as 30-day readmission for a related condition. Multivariable analysis was used to control for the possibility that sicker children were more likely to receive broader-spectrum antibiotics.

Empiric broad-spectrum antibiotics were administered in 33% of children with uncomplicated appendicitis and 66% of children with complicated appendicitis. Treatment failure was 2.7% overall and was higher, as expected, in complicated versus uncomplicated disease (6.4% vs. 1.1%). Treatment failure was higher overall in children treated with extended-spectrum antibiotics, and this difference was statistically significant in those with complicated appendicitis (absolute risk difference, 1.9%).
Kronman MP et al. Extended- versus narrower-spectrum antibiotics for appendicitis. Pediatrics 2016 Jul;138:e20154547. (http://dx.doi.org/10.1542/peds.2015-4547)

COMMENT

Despite the potential for residual confounding in this analysis, the results suggest that use of extended-spectrum antibiotics did not provide any added benefit with respect to preventing treatment failure in children with appendicitis. Broad-spectrum antibiotics, when used widely, lead to increased bacterial resistance in the community and place patients at greater risk for adverse effects such as infection with Clostridium difficile. These study findings suggest that broader is not better, particularly when treating the common pediatric condition of appendicitis.
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