Implementation of an evidence-based protocol after appendectomy reduces unnecessary antibiotics

Background: Children with acute appendicitis have historically received intravenous antibiotics before and after appendectomy, yet recent literature supports minimizing postoperative antibiotics. In this study, we examined the impact of a standardized protocol that eliminates postoperative antibiotics for nonperforated appendicitis and discontinues antibiotics at discharge for perforated appendicitis. Methods: A retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis between May 2013 and March 2017 was performed. Preprotocol patients (5/1/2013–3/31/2015) were compared to postprotocol patients (5/1/2015–3/31/2017), excluding those who underwent surgery during the month of protocol introduction (4/2015). Primary outcomes were postoperative antibiotic doses for nonperforated cases and antibiotics after discharge for perforated cases. Mann–Whitney and Fisher's exact tests were performed. Results: Laparoscopic appendectomy was performed in 748 children before (PRE) and in 814 children after (POST) protocol implementation. Perforation rates were similar (POST 21.5 vs. PRE 21.8%, p = 0.90). For nonperforated appendicitis, postoperative antibiotics were reduced (median 0 [IQR 0–0] vs. 3 [0–5] doses, p < 0.001), and more patients were discharged less than 24 h after surgery (65.7 vs. 40.9%, p < 0.001). Fewer patients with perforated appendicitis underwent PICC placement (8.6 vs. 21.0%, p = 0.002), and fewer patients were prescribed antibiotics on discharge (33.7 vs. 89.0%, p < 0.001). There were no differences between groups for complication, readmission, or return to ED rates. Conclusion: For children with acute appendicitis, a standardized protocol can safely reduce unnecessary antibiotics and decrease length of stay. Furthermore, the judicious use of antibiotics does not increase SSI, readmission, or overall complication rates. Level of evidence: III