Effectiveness of Dual Antibacterial Therapy and Effectiveness of Recommendation Criteria as a Diagnostic Tool in Children with Uncomplicated Acute Appendicitis
Authors: Taurina Liene , Liepina Zane , Zviedre Astra , Engelis Arnis , Petersons Aigars 
Published: November 2020

Summary

Introduction
Acute appendicitis (AA) – acute inflammation and infection of the appendix – is one of the most common cause for abdominal surgery in pediatrics. Appendectomy has been the gold standard since 1735, but in recent years there have been several studies that investigate antibacterial therapy for uncomplicated acute appendicitis. In 2016 new recommendations for suspected AA were implemented in emergency department setting of Children's Clinical University Hospital (CCUH).

Aim of the Study
To evaluate whether diagnostic criteria for patients with a suspected acute appendicitis is effective as a diagnostic tool and to evaluate whether dual antibacterial therapy is safe and effective as first line treatment for children with diagnosis of uncomplicated acute appendicitis in CCUH.

Material and methods
A retrospective study was made in CCUH from January 2017 to December 2017. Patients aged 7 to 18 with suspected uncomplicated acute appendicitis were identified and data were collected from an internal hospital management system and patients’ medical records. Patients were divided into two groups – A and B. In group A were patients who met the criteria of uncomplicated AA, and in group B – patients who met the criteria of complicated AA. Both groups received ampicillin and metronidazole. For statistical analysis IBM SPSS Statistics 22 program was used.

Results
From 98 patients majority were boys (51% (n=50)) with mean age 12.6 years. As a result of antibacterial therapy clinical condition improved in 93% (n=89) of patients who were discharged without surgery. 7 patients did not improve and underwent surgery within 48 hours after admission, another 2 had elective appendectomy. There was a significant positive moderate correlation between C–reactive protein (CRP), white blood cell count (WBC), basophil granulocytes (BASO) and appendix diameter at admisson and after 48 hours of dual antibacterial therapy (r=0.31, p=0.003 vs. r=0.37, p<0.001 vs. r=0.41, p=0.017 vs. r=0.51, p=0.013). In group A (68% (n=67)) there was a significant positive moderate correlation between CRP, WBC and appendix diameter at admission and after 48 hours of dual antibacterial therapy (r=0.31, p=0.003 vs. r=0.37, p<0.001 vs. r=0.51, p=0.013). In group B (30% (n=31)) 7 patients underwent appendectomy and 2 patients received a broad spectrum antibacterial therapy prior to elective appendectomy. There is evidence of significant association between ALVARADO score (p=0.004), rebound tenderness (p<0.001), WBC (p=0.004), CRP (p<0.001) and stage in which appendicitis has progressed to.

Conclusions
Antibiotic-alone treatment may be a safe and effective initial management choice in children with uncomplicated acute appendicitis. However, to fully evaluate effectiveness of antibacterial therapy and diagnostic criteria, further follow–up research is needed.
A normal C–reactive protein value does not rule out uncomplicated acute appendicitis, therefore it can not act as a single marker to diagnose AA or to differentiate between complicated and uncomplicated AA.
Recommendations of treatment of UCAA are acceptable for use in emergency department as they act as a unified tool that allows pediatricians and pediatric surgeons to quickly assess suspected acute appendicitis.