Comparative study of single dose preoperative antibiotics versus preoperative and postoperative antibiotics in laparoscopic appendicectomy for uncomplicated appendicitis in rural hospital

 

Parag V Hawaldar¹, Kavita P Hawaldar^2*

 

Abstract              Background: Antibiotics are being administered both preoperatively and postoperatively even in uncomplicated nonperforated appendicitis. Studies regarding role of postoperative antibiotics in laparoscopic appendicectomy for nonperforated appendicitis are very few. The aim of the study is therefore to study the efficacy of single dose preoperative antibiotics versus both preoperative and postoperative antibiotics in reducing complications like surgical site infection, intra abdominal abscess in laparoscopic appendicectomy for uncomplicated nonperforated acute appendicitis. Methods: This is a prospective study done in general surgery department at Prakash institute of medical sciences, Islampur from November 2020 to January 2021.150 patients with nonperforated appendicitis were randomly allocated into two groups. 75 patients in Group A were given single dose of preoperative prophylactic antibiotics. No further antibiotics were given. 75 patients in Group B were given both preoperative and postoperative antibiotics. Postoperative surgical site infection and duration of postoperative hospital stay were compared between both groups. Statistical analysis was done using ANOVA, Fisher’s Exact test and Chi-square test wherever necessary. Results: There was significant difference in the rate of surgical site infection in group receiving only single dose of antibiotics preop. The mean duration of postoperative hospital stay was shorter in both pre and postoperative antibiotic group (Group B). Age and gender had no significant association with surgical site infection and other complications. There was no deep incisional or intraabdominal infection in this study. Conclusions: Single dose prophylactic antibioticsis not sufficient in cases of laparoscopic appendicectomy for simple uncomplicated nonperforated acute appendicitis in peripheral setup where patient has already taken antibiotics before admission in hospital. Postoperative antibiotics are necessary in pheripheral setup in rural India.

Keywords: Acute appendicitis, Laparoscopic appendicectomy, Nonperforated, Prophylactic antibiotics.

 

INTRODUCTION

Acute Appendicitis is common surgical emergency. Appendicectomy is a clean contaminated surgery.^1,2The lifetime risk for acute appendicitis (AA) is 7 to 8%.²⁹ Rate of wound infection in nonperforated appendicitis is less than 5% to less than 10% after open appendicectomy and even less after laparoscopic appendicectomy.3-7 Prophylactic antibiotics are recommended in appendicectomy.^3,4,8,27 Some Studies reported that postoperative antibiotics may not be needed in nonperforated appendicitis but recent studies suggest need for antibiotics 28 For open appendisectomy ,wound infection rate varies between 5 to 10 percent. And its further less for laparoscopic appendisectomy.^3,7Complicated appendicitis is defined as perforated appendicitis, extraluminal fecaliths, an abscess, or local or generalized peritonitis.³⁰ Prophylactic antibiotics are recommended in appendicectomy.^3,4,8 Studies reported that postoperative antibiotics may not be needed in nonperforated appendicitis.4,8,9In 2014, the world Health Organization published a report on the escalating global incidence of multidrug resistance caused by antibiotic overuse, which has become a significant threat to public health worldwide ³¹ There has thus recently been a tendency to minimize the use of postoperative antibiotics for uncomplicated appendicitis and anorectal abscesses³² But still antibiotics are being used for non perforated appendicitis as a safeguard to avoid postoperative complications but this increases the treatment cost and there is also danger of antibiotic resistance. The aim of the study is therefore to study the efficacy of single dose preoperative antibiotics versus both preoperative and postoperative 2 dose of antibiotics in reducing surgical site infection after laparoscopic appendicectomy for uncomplicated nonperforated acute appendicitis.

 

METHODS

This is a prospective study at Prakash Institute of medical sciences in general surgery department from January 2019 to January 2020. Patients with simple uncomplicated nonperforated acute appendicitis above 16 years of age undergoing laparoscopic appendicectomy were included in the study. Study was approved by institutional human ethics committee.

Informed consent for the study was obtained from patients. Exclusion criteria were patients with perforated appendicitis, appendicular abscess or mass, gangrenous appendicitis, diffuse peritonitis, immunocomprised, comorbidities like diabetes, heart, lung, renal, liver disease, local or generalized infection before surgery, currently taking antibiotics for other ailments, drug allergy, on chemotherapy and steroid therapy, malnutrition, anaemia, American society of anesthesiologists (ASA) score 2 and more, patients who already received antibiotics prior to admission, duration of surgery more than 2 hours, body mass index (BMI) greater than 25, laparoscopic converted to open surgery, pregnancy. Clinical diagnosis of acute appendicitis was made based on history and physical examination. All necessary investigations were done including ultrasound abdomen. Patients were considered to have simple uncomplicated nonperforated acute appendicitis when the symptoms were less than 48 hours duration and no evidence of perforation on imaging and intraoperative findings as mentioned in literature though final confirmation was obtained by histopathological examination. All necessary uniform guidelines of aseptic precautions and management were followed. Operative area was cleaned with Povidone iodine and surgical spirit. The duration of symptoms was recorded from time of onset of symptoms according to the patient until surgery. Patients were given single dose of prophylactic preoperative antibiotics intravenously cefuroxime (1.5gm) and Metronidazole (500 mg) half an hour before skin incision for port placement. Laparoscopic appendicectomy was done using standard three port technique, one 10 mm port subumbilicus and two 5mm ports at suprapubic and left iliac fossa. Mesoappendix was resected with bopolar electrocautery. Appendix was ligated with chromic catgutby endoloop 2 threads at base and one above it was tied. Appendix cut above 2 threads and removed from umbilical trocar site by railroading technique. rectus sheath at umbilicus closed by prolene no 1 and skin with 3-0 Ethilon. No drain was inserted in these cases. Patients with nonperforated appendicitis diagnosed intraoperatively were randomly allocated by opening sealed envelopes into two groups, Group A and Group B. Group A patients were given single dose of prophylactic preoperative antibiotics intravenously Cefuroxime (1.5gm) and Metronidazole (500mg) half an hour before skin incision for port placement. No further antibiotics were given in Group A. Group B patients were given single dose of prophylactic preoperative antibiotics intravenously Cefuroxime (1.5gm) and Metronidazole (500mg) half an hour before skin incision for port placement and were given further one two of Cefuroxime (1.5gm) 12 hourly and three doses of Metronidazole (500mg) 8 hourly intravenously within 24 hours after surgery, further no antibiotics were given Appendix specimen was sent for histopathological examination. Primary outcome was surgical site infection. Patients were monitored in postoperative period. Temperature chart was maintained. Wound dressing was opened after 48 hours and examined for any signs of surgical site infection as defined by Centers For Disease Control and Prevention (CDC) with features of erythema, local edema, fever or discharge of pus that requires surgical drainage. Patients were discharged when they were afebrile (less than37.5 degrees Celsius), had no signs of wound infection, fully mobilized, could tolerate normal oral diet following return of bowel activity, had adequate pain relief with oral analgesics. If patient was discharged, follow up was done on 5th postoperative day. Suture removal was done on 7th postoperative day. In cases of wound infection, swab for culture and sensitivity was sent to microbiology lab. Further follow up was done in all cases for a minimum period of 30 days. Secondary outcome was duration of postoperative hospital stay.

Statistical analysis

Statistical analyses were done using SPSS Statistics version 2.0. Values were presented as mean ± standard deviation or percentages. Fisher’s Exact test and Chi-square test were used wherever necessary. p value of less than 0.05 was considered statistically significant.

Ethical approval: The study was approved by the institutional ethics committee

 

RESULTS

In this study,200 patients were considered for the study. Exclusion of patients was done based on exclusion criteria and due to alternate intraoperative diagnosis. Patients after random allocation were excluded when patients withdrew from study and had alternate diagnosis on final histopathological examination. Finally of 175 patients,75 patients were in Group A (preoperative antibiotics only) and 75 patients in Group B (both preoperative and postoperative antibiotics) (Figure 1). Patients included were in the age group of 16-60 years with no significant difference in age between both groups. Both the groups were comparable with respect to baseline characteristics (Table 1). The rate of surgical site infection in group A was 12% and in group B was 1.3% and the difference was statistically significant (p=0.0366; Chi Square test) (Figure 2).

All the patients with wound infection were superficial surgical site infections detected on 3rd-5th postoperative day and managed by daily normal saline dressings, swab for culture and sensitivity was sent though empirical treatment was given with antibiotics like Amoxicillin Potassium Clavulanate, Metronidazole orally. Wound infection in all cases resolved within 4-6 days and healed by secondary intention. No deep incisional or organ space infection or intraabdominal abscess was found in this study. There was no perioperative mortality. The mean duration of postoperative hospital stay was 1.27±0.58 in group A and in group B was 1.11±0.35 and the difference was found to be significant (p= 0.0425 ANOVA Test) (Table 2). There was significant difference in surgical site infection with in both groups (p= 0.0366); and no significance difference in age (Chi square test) and gender (p=1.00; Fisher’s Exact test).

 

 

 

 

 

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