Antibiotic Treatment in Complicated Appendicitis: Can It Be Optimized?

BACKGROUND: The management of complicated appendicitis is inconclusive. Guidelines have not been established for the use of personalized antibiotic treatment. OBJECTIVES: To investigate specific risk factors to consider during the initial first-choice antibiotic therapy in children with complicated appendicitis. METHODS: This study included all pediatric patients younger than 18 years of age who underwent a laparoscopic appendectomy during 2012-2022 at a single tertiary medical center. RESULTS: In total, 300 pediatric patients underwent laparoscopic appendectomy due to complicated appendicitis. The patients were treated with ceftriaxone + metronidazole (CM). For 57 (19%) patients, the empirical treatment was changed to tazobactam/piperacillin (TP) due to resistant bacteria or clinical deterioration. The presence of generalized peritonitis during surgery and C-reactive protein (CRP) levels above 20 mg/L at admission were identified as risk factors for changing the antibiotic regimen from CM to TP. CONCLUSIONS: Generalized peritonitis and CRP > 20 gr/L were highly correlated with changing the antibiotic regimen to TP. For such patients, initial treatment with TP may result in clinical improvement and shorter hospitalization.

Pediatric and Adolescent Surgical Breast Clinic: Preliminary Experience.

STUDY OBJECTIVE: The diagnostic and treatment tools used in breast centers are largely geared to adults, and there is little consideration of the unique characteristics of breast diseases in younger age groups. Herein we report on the preliminary experience of a specialized breast clinic for children and adolescents. DESIGN: Retrospective, observational. SETTING: Pediatric Surgical Breast Clinic of Schneider Children's Medical Center of Israel. PARTICIPANTS: Patients referred to the clinic during the first 18 months of its establishment. INTERVENTIONS AND MAIN OUTCOME MEASURES: Rate of breast masses, rate of malignancy, and types of evaluation and treatment. RESULTS: Forty-seven patients aged 0-19 years were referred. Breast masses were suspected in 23/47 (48.9%) and confirmed using ultrasound in 14/47 (29.7%; mean age, 16.4 years), followed by needle core biopsy in 7. Seven patients had multiple masses. Breast Imaging and Reporting Data System scores ranged from 3 to 4b. All cases were treated as fibroadenomas. Four patients underwent surgery because of a large mass (>5 cm; n = 3) or patient's preference to remove the lump rather than follow-up (n = 1). There were no malignancies. The median time from patient identification of the mass until seeking medical help was 5 months. CONCLUSION: Several findings distinct to this age group were highlighted: high rate of multiple masses, lack of malignancy, and high risk of delayed diagnosis. Care should be taken when using Breast Imaging and Reporting Data System categorization because it was formulated for adults and might be very limited in the adolescent population. Longer-term studies of larger cohorts are planned.

Perianal abscess in infants: Amenable to conservative treatment in selected cases.

BACKGROUND: Perianal abscess is a common surgical condition in daily pediatric practice. Management is a subject of controversy and a variety of approaches are practiced. While the most frequent approach is drainage with/without fistulotomy, the superiority of this approach and the place of conservative approach has not been established. The aim of this study was to evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants. METHODS: Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital in 2014-2018 were retrospectively reviewed. RESULTS: Criteria for a conservative approach were: spontaneous drainage into the anal canal (n = 8) or perianal skin (n = 4), and phlegmonous infiltrate with fluid collection detected on ultrasound (n = 7). Mean age at symptom onset was 8.4 months. Twelve patients were managed for the first time. Previous care in seven patients included 1-4 drainage procedures (n = 4), spontaneous drainage (n = 1) and antibiotics (n = 2). Five patients were on oral antibiotics at presentation. After diagnosis, 18 patients received i.v. antibiotics and one, oral antibiotics. Three patients (15.7%) ultimately required surgical drainage; two were lost to follow up. During follow up (mean, 22.4 months) four patients (28.5%) had a single recurrent episode; abscess in three (managed conservatively in two and surgically in one) and fistula-in-ano in one patient that healed spontaneously. Thus, surgical intervention was prevented in 13/17 patients (76.4%) available for follow up. CONCLUSIONS: Perianal abscess in infants is amenable to conservative management in selected cases. Avoiding surgical intervention is advantageous, especially given the high recurrence rate.

Point-of-Care Ultrasound in a Department of Pediatric and Adolescent Surgery.

BACKGROUND: Point-of-care ultrasound (POCUS) is becoming a common tool for routine use in emergency medicine, anesthesiology and intensive care for diagnostic and interventional purposes. When a portable ultrasound device became available for the department of Pediatric and Adolescent Surgery at the Schneider's Children Medical Center of Israel, we added POCUS assessments to the physician's daily rounds. POCUS is performed by pediatric surgeons trained in basic ultrasonography skills. Starting September 2015 all POCUS examinations were documented. OBJECTIVES: To describe the current use, diagnostic and therapeutic impacts of POCUS in a department of pediatric and adolescent surgery. METHODS: We conducted an observational study of all the documented POCUS procedures performed during a half-year period. Data regarding patient condition and the POCUS procedures were collected, as well as data on the use of other diagnostic modalities, mainly formal ultrasound exams (by radiologists) and computed tomography scans and their correlation with the POCUS assessment. RESULTS: Fifty-one POCUS exams were performed during the study period, most of which served to define the presence and resolution of a collection - intraabdominal (34%) and subcutaneous (31%). Despite a high rate for formal diagnostic studies (65%), probably due to a relative lack of confidence of surgeons performing the POCUS exams during this initial period, most results (92%) were compatible. CONCLUSIONS: The ability and availability to perform multiple POCUS exams by the attending physician proved to be a valuable aide to the classical physical and laboratory examinations of surgical patients, and we predict its increasing use in quotidian practice.