The Value of Post-operative Antibiotic Therapy After Laparoscopic Appendectomy for Complicated Acute Appendicitis (Other Than for Generalized Peritonitis)

Study Overview
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Brief Summary
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Around 30% of appendectomies are performed for complicated acute appendicitis (CAA, i.e. cases with perforated appendicitis, extraluminal fecaliths, abscesses, or local or generalized peritonitis). The treatment of these complicated forms involves the following steps: initiation of antibiotic treatment at the time of the diagnosis, appendectomy and post-operative antibiotic therapy that continues for 3 days for localized forms of CAA and for 5 days for generalized peritonitis (according to the guidelines issued by the French Society for Anaesthesia and Critical Care Medicine (SFAR)). The results of a Cochrane meta-analysis published in 2005 suggested that the post-operative infection rate was lower in patients having receiving antibiotic therapy after surgery for AA. When only cases of CAA were considered, the difference was no longer significant. However, it should be noted that the studies included in the meta-analysis are now rather old (published before 1995, with open procedures) and no longer provide valid data for answering this question because most appendectomies (80%) are now performed using laparoscopy. Furthermore, a recent cohort study compared a short (3-day) course of antibiotics with a long course (at least 5 days) in patients with CAA having undergone laparoscopic or open appendectomy. There was no significant intergroup difference in the post-operative complication rate. One can thus legitimately question whether post-operative antibiotic therapy is required after laparoscopic appendectomy for CAA. The purpose of the present study is to evaluate the impact of the absence of post-operative antibiotic therapy on the organ space surgical site infection (SSI) rate in patients presenting with CAA (other than cases of generalized peritonitis) by comparing a group of patients having undergone a conventional strategy of post-operative antibiotic therapy for three days after appendectomy for CAA (the control group) with a group of patients having received a post-operative placebo for three days after appendectomy for CAA (the experimental group). The primary endpoint will be evaluated at one month after randomization.

Official Title
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The Value of Post-operative Antibiotic Therapy After Laparoscopic Appendectomy for Complicated Acute Appendicitis (Other Than for Generalized Peritonitis): a Prospective, Randomized, Placebo-controlled Phase III Study

Conditions
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Complicated Acute Appendicitis

Intervention / Treatment
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* Other: No antibiotics
* Drug: Antibiotics


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: CAA suspected pre-operatively through a Saint-Antoine score ≤3 and confirmed peroperatively by the presence of a perforated appendicitis, extraluminal fecaliths, abscesses and/or localized peritonitis (pus in one or two abdominal quadrants). Laparoscopic appendectomy. Aged 18 or over Written, informed consent Exclusion Criteria: Pre-operative exclusion criteria: Patients with cardiac valvulopathy Immunodepressed patients Diabetic patients Patients who have received an antibiotic treatment within 3 months before the surgery (and having a potential impact on the intestinal flora) Related to the diagnosis: other diseases (Crohn's disease, ulcerative colitis, treatment with an immunosuppressive therapy). Related to the severity of the appendicitis: A Saint-Antoine score of 4 or 5 (non-complicated acute appendicitis) Severe sepsis, septic shock, generalized peritonitis Related to the treatment: A decision to perform open appendectomy. Patients who received an adaptive dose of Levofloxacine 250 mg/24H instead of 500 mg/24H in pre-operative or in per-operative (notably for patients with creatinine clearance ≤ 50 ml/min) allergy to metronidazole or to one of the excipient Contra-indication to the use of ceftriaxone (hypersensibility to the active substance, to another cephalosporin, to the excipient of the used speciality), history of severe hypersesibility (as anaphylactic shock), history of hypersensibility to another antibiotic of the beta-lactamin family (penicillin, monobactam, carbapénèmes) Contra-indication to the use of levofloxacin, hypersensibility to levofloxacin, to another quinolone or to the excipient of one of the use speciality, hypersensibility to levofloxacine ou any other quinolone or to any excipient, epilepsia, history of tendinitis when injection of fluoroquinolones. Related to the patient Living at more than one hour from an hospital Patient who has no relative or other third person who could be present at home and provide assistance in case of any problem for the discharged patient Per-operative exclusion criteria (related to the severity of appendicitis): Non-complicated forms (catarrhal appendicitis or the absence of extraluminal fecaliths, abscess or peritonitis). Generalized purulent or stercoral peritonitis (the presence of pus or faeces in more than two quadrants of the abdomen). In order to assess the reproducibility of the inclusion criteria in the various centres and to avoid variations due to the lack of an official definition for localized peritonitis, all centres will receive a video tutorial on localized peritonitis before the start of the study. Pregnancy or breastfeeding. Patients under guardianship. Patients unable to provide informed consent. Patient lacking social security coverage Allergy to metronidazole

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: experimental group<br>no antibiotherapy post surgery for complicated acute appendicitis (CAA) | Other: No antibiotics<br>* Patients will not receive antiobitherapy post surgery for CAA<br>|
| Active Comparator: control group<br>antibiotherapy post surgery for complicated acute appendicitis (CAA) | Drug: Antibiotics<br>* Patients will receive antiobitherapy post surgery for CAA<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| proportion of patients having developed organ space surgical site infections (SSIs) by postoperative day (POD)30 | primary outcome is the proportion of patients with deep SSIs by POD30. Deep SSIs are officially defined by the CDCcentre of disease control and prevention (CDC) as infections that occur within 30 days of surgery AND appear to be related to the surgery AND affect the organ or the cavity around the surgical site (i.e. any anatomical structure - other than the incision - that is opened or handled during surgery) AND for which at least one of the following signs is observed: pus coming from a drain placed in the organ or cavity; germs isolated from a liquid or tissue sample collected aseptically from the organ or cavity; an abscess or another obvious sign of infection of the organ or cavity found by macroscopic examination during subsequent surgery or in a radiological or histopathological examination. | postoperative day 30 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Quality of life post surgery using the 36-Item Short Form Health Survey | Quality of life on day 0 and day 30 post surgery, with the 36-Item Short Form Health Survey questionnaires (0 = very bad, 100 = very good) | day 0 and day 30 | 
| proportion of patients with superficial SSIs | The proportion of patients with superficial SSIs, defined as infections that occur within 30 days of the intervention AND affect the skin and subcutaneous tissue AND or which at least one of the following signs is observed: pus coming from the superficial part of the incision, germs isolated from a liquid or tissue sample collected aseptically from the superficial part of the incision, a sign of infection (pain, tenderness, redness, burning, etc.) associated with deliberate opening of the superficial part of the incision by the surgeon (except if the culture is negative). Infection of the superficial part of the incision is diagnosed by the surgeon (or the physician attending to the patient). | postoperative day 30 | 
| post-operative infection rates | post-operative infection rates by POD30, including SSIs and remote infections. | postoperative day 30 | 
| number of antibiotic-free days | number of antibiotic-free days between randomization and POD30 | postoperative day 30 | 
| Description of the microbial flora | Description of the microbial flora found in the antibiogram of the per-operative sample collected in all cases | Day 0 | 
| balance between antibiotic therapy and microbial resistance | balance between antibiotic therapy and microbial resistance | postoperative day 30 | 
| Evaluation of morbidity and mortality | Evaluation of morbidity and mortality (according to the Dindo-Clavien classification and the Comprehensive Complication Index (CCI)). | postoperative day 30 | 
| Length of hospital stay | Length of hospital stay, defined as the number of days of hospitalization between surgery and discharge | postoperative day 30 | 
| rehospitalization rate | rehospitalization rate, defined as the proportion of patients rehospitalized during the study | postoperative day 30 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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complicated acute appendicitis, post-operative antibiotic therapy