Newman et al. reported that the perforation rates for appendicitis at 30 children's hospitals in the U.S. ranged from 20%–76% (mean, 36%)[14]. Clinical acute PA is a common complication of pediatric appendicitis because the cecum is free in children, the appendix wall is thin and rich in lymphoid tissue, retinal dysplasia is common, and the peritoneal cavity surface is large. This increases the possibility of PA, leading to celiac inflammation and severe difficulty in controlling the infection, leading to more complications[15]. Tsai et al. suggest that surgery is the best option for early treatment of PA in children and can shorten the antibiotic treatment course and hospital stay[16]. In our study, common postoperative complications included ascites, intestinal obstruction, abdominal infection, and incision infections; however, postoperative complications did not significantly differ between the CBP and CPS groups. Schulin et al. found that in acute pediatric appendicitis, the appendix microbiome is highly diverse, with significant differences in the microorganismal compositions in the lumen of the appendix according to the degree of inflammation, which may be the cause of increased pathogenic bacteria in the appendix[17].
Antibiotics play vital roles in treating pediatric PA. However, no uniform standards exist for the use of antibiotics after surgery for pediatric appendicitis[18], and antibiotics are often severely abused, leading to more drug-resistant bacterial strains, thus making it difficult to achieve the ideal effect using conventional drugs. Some scholars believe that based on clinical experience, use of restriction-grade broad-spectrum antibiotics reduces the occurrence of postoperative complications, shortens hospital stay lengths, and reduces treatment costs. Some even suggest cancelling intraoperative pus cultures and antimicrobial susceptibility testing[19]. Plattner et al. yielded a more convincing conclusion that in non-critically ill children, routine use of broad-spectrum antibiotics or continued use of antibiotics after discharge was not associated with improved clinical treatment outcomes[20]. Therefore, choosing the appropriate antibiotics for treatment is a concern for many scholars. As per Turel et al.[21], clinicians should select appropriate antibiotics according to the test results for pathogenic bacteria to guide the clinical treatment of PA in children. We believe that peritoneal pus culturing is inexpensive, convenient, economical, and effective in clinical applications. Pus cultures from our included cases revealed that multiple bacterial coinfections were common, such as E. coli and P. aeruginosa coinfections in nine cases (22.0%). Additionally, E. coli and P. aeruginosa were highly sensitive to third-generation CPSs (i.e., ceftazidime and ceftizoxime). These antibiotics can be considered generally sensitive for the pathogens causing PA. Therefore, these two CPSs were the preferred empirical agents, pending susceptibility testing results. Our susceptibility test results suggested that some bacteria were susceptible to CBPs and resistant to CPSs. However, the existing literature does not include CBPs in first-line antibiotic regimens for treating PA. We hope that our results show the potential for CBP use. Some scholars have proposed a management plan for the use of CBPs[22]. The use of restricted-grade broad-spectrum antibiotics increases the risk of colonization and infection by multidrug-resistant microorganisms[23, 24]. Specifically, increased empirical use of meropenem simultaneously increases the number of CBP-resistant gram-negative bacteria[25], which must be prevented. In this study, bacteria were sensitive to CPSs, penicillins, and aminoglycosides, which may be the top choices for empirical treatment. However, studies have reported that resistance of E. coli to penicillins such as amoxicillin-clavulanic acid leads to increased postoperative complications[26]. Additionally, although aminoglycosides are effective against most bacilli and P. aeruginosa, they can cause nephrotoxicity[27] and ototoxicity[28], which are harmful to children. Therefore, we avoid using aminoglycosides and used CPSs as our main drug and research focus.
Among observable laboratory indicators, white blood cells (WBCs) are inflammatory cells, and their exudate is an essential feature in inflammatory responses. However, WBC counts can vary within a specific range at different times and different functional states of the body, and some physiological factors, including age, pain, and emotional changes, affect WBC counts. In some patients with severe infections, the WBC count decreases rather than increases and lacks specificity for judging the severity of acute appendicitis[29]. Thus, we excluded it from the withdrawal criteria. Because CRP is one of the most sensitive markers of acute phase reactions in humans, CRP content can increase rapidly during acute inflammatory responses. Its concentration and levels are mostly unaffected by physiological factors and antibiotics and are positively correlated with the degree of infection. Previous studies showed that CRP levels were positively correlated with appendicitis severity in children with acute appendicitis, especially complicated PA[30, 31]. Therefore, we included CRP in our evaluation comparison standard. We compared the CRP recovery times and hospital stay lengths between the two groups and found significant advantage in the efficacy of CBP use.Also we compared GF recovery times between the two groups and found no significant advantage in the efficacy of CBP use.
Our study had several strengths and weaknesses. To avoid potential bias regarding the definition of PA[32], we used an unequivocal intraoperative definition and considered only a selection of individuals within a closely circumscribed study population. Pediatric PA is prone to systemic infection, especially in children with weakened immune barrier functions, which is more likely to cause bacteremia, sepsis, and other serious infections, often involving antibiotic combinations or upgraded medication. To reduce the influence of such factors on our results, we limited the study to children without immunodeficiencies or hemodynamic problems. Therefore, other potential confounding factors, including WBC counts, degree of abdominal contamination, and operation time conclusions were more objective and accurate[33, 34]. A recent randomized controlled trial evaluated the relationship between antibiotic duration and postoperative abdominal infection[35, 36]. However, our study was limited to a review of case records from our institution and lacked an analysis of the effect of antibiotic duration on postoperative outcomes in PA. Children with secondary complications after discharge may have been excluded in the statistics; thus, these results could not be reported. In addition, we classified the treatment groups by initial antibiotic treatment (within 24 hours after admission), postoperative antibiotics may have changed the results. However, because this occurs in only a small number of patients, we chose this classification method in advance because we assumed that the final antibiotic choice will have a greater influence on postoperative PA outcomes and minimize the risk of confusion.