Are Post-operative Antibiotics Indicated in Simple Appendicitis?

Are Post-operative Antibiotics Indicated in Simple Appendicitis? a Prospective Randomized Trial

Hypothesis: A single dose of prophylactic antibiotics is as effective as a three dose regime in preventing post-operative complications in paediatric patients with simple appendicitis.

This project will compare patients 16 years and under with simple appendicitis (appendicitis that is not perforated or gangrenous). Patients will be randomly divided into two groups;

• Group one will receive a single pre-operative dose of antibiotics (metronidazole 12.5mg/kg up to 500mg and cefazolin 25mg/kg up to 1g) and two 'doses' of normal saline (placebo) eight and sixteen hours after the initial dose, respectively.
• Group two will receive one pre-operative dose of antibiotics (metronidazole 12.5mg/kg up to 500mg and cefazolin 25mg/kg up to 1g) and two post-operative doses, eight and sixteen hours after the first dose, respectively.

Group allocation will be concealed from the patient and their guardian, the treating surgical team and outcome assessors (triple blinded). A process to rapidly reveal group allocation if required will be in place.

The aim of the study is to determine if a single dose of antibiotics is as effective as three doses in preventing post-operative infection. This will be assessed by comparing:

• Duration of hospital stay from operation until discharge, based on a standardised discharge criteria.
• Development of wound infection or requirement of antibiotics in the six weeks post-operation
• Need for re-admission.

Information will be collected prospectively from each patient's hospital notes and from a follow-up phone call six weeks after the operation.

Study Overview

• Status: Completed
• Conditions: Appendicitis
• Intervention / Treatment: Drug: metronidazole and cephalzolin

• Study Type: Interventional
• Enrollment (Actual): 300
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Australia
  • Victoria
    • Clayton, Victoria, Australia, 3168
      • Monash Medical Centre

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 4 years to 17 years (Child)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• All patients who have their appendix removed and are found on operation to have 'simple appendicitis' as defined in the Cochrane review[7]. That is an appendix that is non-inflamed, acutely inflamed, phlegmonous, suppurative or mildly inflamed.

Exclusion Criteria:

• Patients who on operation are found to have 'complicated appendicitis' defined as an appendix that is gangrenous or perforated.
• Patients who pre-operatively appear to be acutely septic or for another reason require extended antibiotic therapy.
• Patients who, at operation, are found to have other pathology e.g. Meckel's Diverticulum, Intussusception; requiring surgical or medical intervention.
• Any patient whose guardian does not wish for them to participate in the study.
• Patients who have additional co-morbidities, including diabetes, immuno-suppression, cardiac, renal or liver failure.
• If the child continues to show sign of sepsis, in terms of fever, tachycardia, he/she will be discontinued from the study and be given additional doses of antibiotics, as clinically indicated.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Single dose of antibiotics; This group will receive one dose of IV metronidazole (12.5mg/kg up to 500mg) and cefazolin (25mg/kg up to 1g) in the pre-operative period and two post-operative IV 'doses' of normal saline 8 and 16 hours after the pre-operative dose, which will act as a placebo and facilitate blinding.	Drug: metronidazole and cephalzolin; IV doses of metronidazole (12.5mg/kg up to 500mg) and cefazolin (25mg/kg up to 1g). One dose for study arm, two for comparative arm.
Active Comparator: Three doses of antibiotics; This group will receive one pre-operative dose of IV metronidazole (12.5mg/kg up to 500mg) and cefazolin (25mg/kg up to 1g) and two post-operative doses of IV metronidazole (12.5mg/kg up to 500mg) and cefazolin (25mg/kg up to 1g) 8 and 16 hours after the pre-operative dose.	Drug: metronidazole and cephalzolin; IV doses of metronidazole (12.5mg/kg up to 500mg) and cefazolin (25mg/kg up to 1g). One dose for study arm, two for comparative arm.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Presence of post-operative infection in the six weeks following appendectomy	Defined by wound infection, fever (>38.5) or evidence of sepsis.	6 weeks
Requirement of further antibiotic therapy in the six weeks following appendectomy	Administration of antibiotics either by hospital or general practitioner in the 6 week post-operative period.	6 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to discharge taken from the time of operation to the time the child first satisfied the discharge criteria	Discharge criteria: Pain adequately controlled with oral analgesia Tolerating full diet Afebrile	1 week
Re-admission in the six weeks following appendectomy	Re-admission to the treating hospital or any other hospital in the 6 weeks post-operative period.	6 weeks

Collaborators and Investigators

• Sponsor: Monash University
• Collaborators: Monash Medical Centre
• Investigators: Principal Investigator: Nicole Mennie, MBBS, Monash University; Study Director: Wei Cheng, MBBS, Monash Medical Centre

Study record dates

Study Major Dates

• Study Start (Actual): November 1, 2011
• Primary Completion (Actual): November 1, 2013
• Study Completion (Actual): December 1, 2013

Study Registration Dates

• First Submitted: August 18, 2011
• First Submitted That Met QC Criteria: August 18, 2011
• First Posted (Estimated): August 19, 2011

Study Record Updates

• Last Update Posted (Actual): December 2, 2024
• Last Update Submitted That Met QC Criteria: November 27, 2024
• Last Verified: August 1, 2011

More Information

Terms related to this study

• Keywords: Paediatric; Simple; Non-perforated
• Additional Relevant MeSH Terms: Intestinal Diseases; Infections; Digestive System Diseases; Gastrointestinal Diseases; Gastroenteritis; Cecal Diseases; Intraabdominal Infections; Appendicitis; Anti-Bacterial Agents; Anti-Infective Agents; Antiprotozoal Agents; Antiparasitic Agents; Metronidazole
• Other Study ID Numbers: U1111-1123-7877