Bacterial
Flora of Appendicitis By H. Harlan
in Children
Stone
R
ECENT INTEREST in the incidence and relative importance of anaerobes in the microbial flora of established peritonitis has led to the often empiric use of agents specifically directed against anaerobic bacteria.‘** Indeed, on occasion such a change in antimicrobial therapy has been made so as to eliminate antibiotics against aerobic species altogether.2 At times the supportive arguments have appeared sound, yet basic objective data are entirely lacking.‘*2 METHOD
AND
STUDY
In an effort to provide information relative to the incidence and consequences of anaerobes as well as aerobes in the peritoneal flora of children with appendicitis, both aerobic and anaerobic cultures of peritoneal fluid were taken immediately upon surgical entry to the abdomen for appendectomy in all children admitted to the pediatric surgical and trauma services of Grady Memorial Hospital during a 2-yr period. Enriched prereduced peptone broth was innoculated with 2 ml of purulent exudate by the surgeon himself. The culture was mixed by shaking, a gas escape valve was applied, and the innoculated tube was then placed in the operating-room incubator. Time elapsed from opening of the peritoneum until incubation of an anaerobic culture was always less than 2 min. Follow-up cultures on any complicating infection of the abdomen and/or surgical wound were similarly cultured. All aerobic bacterial isolates underwent standard bacteriologic speciation and antibiotic sensitivity testing by both disc and tube dilution methods.’ The same studies were carried out on the anaerobic isolates, but according to the VP1 procedure manual.4 Pertinent clinical findings and hospital course of all patients were recorded, with particular reference to duration of symptoms, localization of abdominal pain and tenderness, temperature, leukocytosis, stage of appendicitis noted at operation, and incidence as well as site of postoperative infections. The various items were then analyzed according to stage of appendicitis and presence of anaerobes in the peritoneal flora. RESULTS
Between April 1, 1973 and March 31, 1975 appendectomy was performed on 114 children 16 yr of age or younger. There were 80 blacks and 34 whites, 70 males and 44 females. Preoperative routines included intravenous hydration with Ringer’s lactate until an adequate urine output had been established, a nasogastric tube connected to constant suction, and selective use of antibiotics, either singly or in combination (cephalothin, clindamycin, gentamicin, tobramycin, sisomicin, or amikacin). The likelihood of appendiceal gangrene or perforation was greater in the younger age groups (Table 1). This may well have been reflected by the relative rarity of appendicitis in preschool children and the limited ability of the younger child to relate his symptoms accurately to a parent or guardian.
From the Department
of Surgery, Emory
Presented before the XXII geons, Newcastle Address for sity School 0 I976
International
University School of Medicine. Congress of the British
upon Tyne. England, July 30-August
reprint
requests: H.
ofMedicine,69
Harlan
Stone,
Go. of Paediatric
Sur-
I, 1975. M.D..
Butler Street, S.E., Atlanta,
by Grune Cc Stratton,
Atlanta,
Association
Department
of Surgery,
Emory
Univer-
Ga. 30303.
Inc.
~ourna/ of Pediatric Surgery, Vol. 11, No. 1 (Febwary),
1976
37
H. HARLAN STONE
38
Table I. Age ond Stage of Appendicitis Incidence (0~)
Gangrenousor Perforated
Numberof Children
Age Range (vr) O-6
12
10
83
7-12
43
18
42
13-16
59
17
29
45
39
Total
F4
Gangrene and perforation were associated with a duration of symptoms longer than 36 hr, diffuse rather than localized abdominal tenderness, a temperature of 38°C or greater, and leukocytosis in excess of 13,OOO/sq mm (Table 2). A similar relationship to stage of appendicitis was also noted with respect to presence of aerobic and anaerobic bacteria in the peritoneal flora (Table 3). Aerobes populated the peritoneal exudate in a third of patients with mere simple (hyperemic) appendicitis and in almost all whose appendicitis had progressed to suppuration. Anaerobes did not appear in the peritoneal flora until appendiceal gangrene had occurred. With gross perforation, all patients had multiple (l-9) anaerobic species in the peritoneal fluid. Even more striking was the correlation between peritoneal bacterial flora on the one hand, and stage of appendicitis, temperature, and white blood count on the other (Table 4). A temperature over 38°C and a white blood count greater than 13,OOO/sq mm were indicative, with but a single exception, of anaerobic participation in the peritoneal flora. There was one death, due to a cardiac arrest during appendectomy in a 2-yrold girl just resuscitated from the septic shock of generalized peritonitis. The incidence of postoperative wound and intraabdominal infections was to some degree determined by the stage of appendicitis (Table 5); only two wound infections and one intraabdominal abscess developed in patients with a nongangrenous or nonperforative appendicitis. However, the presence of anaerobic species in the peritoneal exudate was more critical to the subsequent evolution of infection in the wound or abdomen (Table 6). With a single exception, all such infections developed only in patients from whom anaerobes had been isolated initially from the peritoneal cavity. Cultures of all complicating intraabdominal abscesses contained both aerobic and anaerobic species (Table 7). Although two children had wound infections from which only aerobic bacteria could be identified, each of the remainder loble 2. Signs, Symptoms, and Stage of Appendicitis in 108 Children Undergoing Emergency Appendectomy
stageof Appendicitis
Numberof Children
Duration > 36 hr(%)
Diffuse Tenderness (%)
Temperature > 38°C (%)
Leukocytosir > 13,000/rq mm(%)
Simple
24
4
a
0
Suppurative
30
13
18
21
13
Gangrenous
12
92
92
03
03
Perforated
29
100
100
93
100
Abscessed
5
100
20
100
100
108
47
46
48
45
Total
BACTERIAL
FLORA
39
Table 3.
Peritoneal Bacterial Flora in Appendicitis
stageof
Number of
Aerobe
Anaerobe
Sterile
Appendicitis
Children
Present (%)
Present (%)
Culture (%)
Simple
24
38
Suppurative
38
95
5
Gangrenous
12
100
03
Perforated
29
97
100
-
Abscessed
5
100
100
-
Interval
6
17
-
83
114
80
Total
-
42 5 -
19
40
Table 4. Signs, Symptoms, and Peritoneal Flom in 106 Children Undergoing Emergency Appendectomy Bacterioloav
No growth Aerobe
Number of
Duration
Diffuse
Temperature
Children
> 36 hr (%)
Tenderness (%)
> 38’C (%I
17
only present
Anaerobes Total
-
-
Leukocytosis > 13.000/sa
-
1%)
-
45
22
24
13
9
46
09
85
100
90
108
47
46
48
45
Table 5. Postoperative Wound and lntraabdominal Infections stage of
Number of
Wound
Appendicitis
Children
Infection (96)
Simple
24
lntroobdominol
-
Abscess
Suppurative
38
5
3
Gangrenous
12
25
8
Perforated
29
31
10
Abscessed
5
100
40
Interval
6
-
-
Total
114
(%)
-
17
6
Table 6. Peritoneal Flom and Postoperative Infections in 108 Children Undergoing Emergency Appendectomy Bacteriology
Number of
Wound
Children
Infection (%) -
introabdominal Abscess (%) -
No growth
17
Aerobe
45
2
46
39
15
108
18
6
only
Anaerobes
present
Total
Table 7. Postoperative Infections Site of
Number of
Aerobe
Anoerobe
Infection
Children
Present (%)
Present (%)
19
100
89
7
100
100
26
100
92
Wound lntraabdominol Total
40
H.
Toble 8.
HARLAN
Aerobic Bacteria Isolated from Peritoneal Fluid of
91 of 114 Children Undergoing Appendectomy Bacteria
Number
Incidence (%)
Escherichiaco/i
74
81
Klebsiello-Enterobocter
36
40
Proteus
32
35
Pseudomonas oeruginoso
3
3
Miscellaneous gram-negative rods
17
19
Enterococci
27
30
Miscellaneous gram-positive cocci
2
2
Other
2
Total
193
2 -
Table 9. Anaerobic Bacteria Isolated from Peritoneal Fluid of 46 of 114 Children Undergoing Appendectomy Bacteria
Number
Incidence (or61
Bocteroides
44
96
8. frogilis
39
85
&bacteria
21
46
Cfosfridio
17
37
Propionibocferio
16
35
Peptostrepfococci
18
39
Pepfococci
16
35
Miscellaneous
40
07 -
172
Total
Table 10. Aerobic Bacteria Isolated from Postoperative Infections in 21 of 114 Children Undergoing Appendectomy Bacteria
Number
Escherichio co/i
17
Klebsiek-Enterobocter
11
52
8
38
ProfeLls
81
Pseudomonas oeruginoso
1
5
Miscellaneous gram-negative rods
7
33
10
40
Enterococci Miscellaneous gram-positive cocci
1
5
Other
2
10
Total
-
57 Table 11. Anaerobic krcteria Isolated from PostoPemtive Infections in 19 of 114 Children Undergoing Appendectomy Bacteria
NUIlhM
Incidence (%)
Bacteroides
19
8. frogilis
17
89
9
47
Eubocterio Clostridk
100
3
16
Propionibacterio
11
58
Peptostreptococci
11
58
Peptococci
10
53
Miscellaneous
19
100
Total
99
STONE
BACTERIAL
FLORA
41
had a symbiotic infection due to participation by both major groups of organisms. Although no bacterial growth was noted on culture of the peritoneal fluid from 23 of the children, 193 different aerobic isolates were obtained from the remaining 91 cases. This gave an average of 2.1 aerobic species per positive culture. The incidence of anaerobes being present was less, occurring in only 46 of the children. However, 172 different anaerobes were cultured, thereby giving an average of 3.7 anaerobic species per positive culture. The various aerobic and anaerobic isolates are given in Tables 8 and 9, respectively. Similar bacteriologic results with respect to number of species were noted in cultures of postoperative wound and intraabdominal abscesses (Tables 10 and 11). DISCUSSION
Prior studies have correlated the event of appendiceal gangrene and perforation with four easily obtainable parameters: (1) duration of symptoms longer than 36 hr; (2) diffuse abdominal pain and tenderness; (3) temperature over 38°C; and (4) white blood count in excess of 13,OOO/sq mm.6 Parameters (1) and (2) are closely related to the transperitoneal spread of the infectious process, while (3) and (4) reflect contamination of the peritoneal cavity by anaerobic bacteria, which occurs only after gross or microscopic appendiceal perforation. As has been documented by many previous studies as well as reiterated in the present report, infectious complications of appendicitis are primarily sequels to a disease that has progressed to perforation. ‘s6It is not necessary for absolute gross perforation to have occurred; microscopic perforation, i.e., gangrenous appendicitis, can produce an identical inoculation of the peritoneum and surgical incision with almost the same incidence as later infectious complications.6 More critical to the development of postoperative infection, however, is the presence of anaerobic as well as aerobic species.‘s2s5 The polymicrobial flora thereby created are far more virulent and involve a much greater rate of infectious complications than does any aerobic component alone.‘*2*5 The basic treatment of anaerobic sepsis is the conversion of the area of infection to an aerobic environment. Such is accomplished by excision of all necrotic tissue and subsequent exposure of the resultant wound to atmospheric oxygen. Just the brief period during which the abdomen is opened at appendectomy has been shown to reduce dramatically the anaerobic population.2 Nevertheless, if a facultative or even strict aerobe is present in the immediate vicinity of the anaerobic pathogen, the symbiotic support thereby rendered by the aerobic partner can maintain both life and virulence of the anaerobe despite relatively good local perfusion and thus normal oxygen tensions. Under these circumstances the anaerobe can be eradicated by elimination of its aerobic counterpart. Such a mechanism of action readily explains the excellent, though all too often temporary, benefit obtained by an antibiotic effective only against aerobic species in the control of polymicrobial peritoneal sepsis.2 SUMMARY
Aerobic and anaerobic cultures were taken immediately upon operative entry to the peritoneal cavity of 114 consecutive children undergoing appendectomy.
42
H. HARLAN
STONE
Stage of appendicitis and clinical presentation could be closely correlated to specific patterns of peritoneal bacterial flora. It was found that appendiceal gangrene and perforation uniformly produce a polymicrobial peritonitis that is based on the symbiosis of aerobes with anaerobes. Ensuing wound and intraabdominal septic complications were likewise mixed infections. Based on these findings, refinements in the diagnosis of appendiceal gangrene and perforation as well as rationales in the treatment of appendicitis have been discussed. REFERENCES I. Gorbach SL, Bartlett JG: Anaerobic infections. N Engl J Med 290:1177,1237,1269, 1974 2. Stone HH, Kolb LD, Geheber CE: Incidence and significance of intraperitoneal anaerobic bacteria. Ann Surg 181:705, 1975 3. Bauer AW, Kirby WMM, Sherris JC. et al: Antibiotic susceptibility testing by a standardized single disc method. Am J Clin Pathol 45:493, 1966
4. Holdeman LV, Moore WEC: Anaerobe Laboratory Manual. Blacksburg, Va, VP1 Laboratory, 1972 5. Altemeier WA: The bacterial flora of acute perforated appendicitis with peritonitis. Ann Surg 107517, 1938 6. Stone HH, Sanders SL, Martin JD Jr: Perforated appendicitis in children. Surgery 69: 673, 1971
Flora of Appendicitis By H. Harlan
in Children
Stone
R
ECENT INTEREST in the incidence and relative importance of anaerobes in the microbial flora of established peritonitis has led to the often empiric use of agents specifically directed against anaerobic bacteria.‘** Indeed, on occasion such a change in antimicrobial therapy has been made so as to eliminate antibiotics against aerobic species altogether.2 At times the supportive arguments have appeared sound, yet basic objective data are entirely lacking.‘*2 METHOD
AND
STUDY
In an effort to provide information relative to the incidence and consequences of anaerobes as well as aerobes in the peritoneal flora of children with appendicitis, both aerobic and anaerobic cultures of peritoneal fluid were taken immediately upon surgical entry to the abdomen for appendectomy in all children admitted to the pediatric surgical and trauma services of Grady Memorial Hospital during a 2-yr period. Enriched prereduced peptone broth was innoculated with 2 ml of purulent exudate by the surgeon himself. The culture was mixed by shaking, a gas escape valve was applied, and the innoculated tube was then placed in the operating-room incubator. Time elapsed from opening of the peritoneum until incubation of an anaerobic culture was always less than 2 min. Follow-up cultures on any complicating infection of the abdomen and/or surgical wound were similarly cultured. All aerobic bacterial isolates underwent standard bacteriologic speciation and antibiotic sensitivity testing by both disc and tube dilution methods.’ The same studies were carried out on the anaerobic isolates, but according to the VP1 procedure manual.4 Pertinent clinical findings and hospital course of all patients were recorded, with particular reference to duration of symptoms, localization of abdominal pain and tenderness, temperature, leukocytosis, stage of appendicitis noted at operation, and incidence as well as site of postoperative infections. The various items were then analyzed according to stage of appendicitis and presence of anaerobes in the peritoneal flora. RESULTS
Between April 1, 1973 and March 31, 1975 appendectomy was performed on 114 children 16 yr of age or younger. There were 80 blacks and 34 whites, 70 males and 44 females. Preoperative routines included intravenous hydration with Ringer’s lactate until an adequate urine output had been established, a nasogastric tube connected to constant suction, and selective use of antibiotics, either singly or in combination (cephalothin, clindamycin, gentamicin, tobramycin, sisomicin, or amikacin). The likelihood of appendiceal gangrene or perforation was greater in the younger age groups (Table 1). This may well have been reflected by the relative rarity of appendicitis in preschool children and the limited ability of the younger child to relate his symptoms accurately to a parent or guardian.
From the Department
of Surgery, Emory
Presented before the XXII geons, Newcastle Address for sity School 0 I976
International
University School of Medicine. Congress of the British
upon Tyne. England, July 30-August
reprint
requests: H.
ofMedicine,69
Harlan
Stone,
Go. of Paediatric
Sur-
I, 1975. M.D..
Butler Street, S.E., Atlanta,
by Grune Cc Stratton,
Atlanta,
Association
Department
of Surgery,
Emory
Univer-
Ga. 30303.
Inc.
~ourna/ of Pediatric Surgery, Vol. 11, No. 1 (Febwary),
1976
37
H. HARLAN STONE
38
Table I. Age ond Stage of Appendicitis Incidence (0~)
Gangrenousor Perforated
Numberof Children
Age Range (vr) O-6
12
10
83
7-12
43
18
42
13-16
59
17
29
45
39
Total
F4
Gangrene and perforation were associated with a duration of symptoms longer than 36 hr, diffuse rather than localized abdominal tenderness, a temperature of 38°C or greater, and leukocytosis in excess of 13,OOO/sq mm (Table 2). A similar relationship to stage of appendicitis was also noted with respect to presence of aerobic and anaerobic bacteria in the peritoneal flora (Table 3). Aerobes populated the peritoneal exudate in a third of patients with mere simple (hyperemic) appendicitis and in almost all whose appendicitis had progressed to suppuration. Anaerobes did not appear in the peritoneal flora until appendiceal gangrene had occurred. With gross perforation, all patients had multiple (l-9) anaerobic species in the peritoneal fluid. Even more striking was the correlation between peritoneal bacterial flora on the one hand, and stage of appendicitis, temperature, and white blood count on the other (Table 4). A temperature over 38°C and a white blood count greater than 13,OOO/sq mm were indicative, with but a single exception, of anaerobic participation in the peritoneal flora. There was one death, due to a cardiac arrest during appendectomy in a 2-yrold girl just resuscitated from the septic shock of generalized peritonitis. The incidence of postoperative wound and intraabdominal infections was to some degree determined by the stage of appendicitis (Table 5); only two wound infections and one intraabdominal abscess developed in patients with a nongangrenous or nonperforative appendicitis. However, the presence of anaerobic species in the peritoneal exudate was more critical to the subsequent evolution of infection in the wound or abdomen (Table 6). With a single exception, all such infections developed only in patients from whom anaerobes had been isolated initially from the peritoneal cavity. Cultures of all complicating intraabdominal abscesses contained both aerobic and anaerobic species (Table 7). Although two children had wound infections from which only aerobic bacteria could be identified, each of the remainder loble 2. Signs, Symptoms, and Stage of Appendicitis in 108 Children Undergoing Emergency Appendectomy
stageof Appendicitis
Numberof Children
Duration > 36 hr(%)
Diffuse Tenderness (%)
Temperature > 38°C (%)
Leukocytosir > 13,000/rq mm(%)
Simple
24
4
a
0
Suppurative
30
13
18
21
13
Gangrenous
12
92
92
03
03
Perforated
29
100
100
93
100
Abscessed
5
100
20
100
100
108
47
46
48
45
Total
BACTERIAL
FLORA
39
Table 3.
Peritoneal Bacterial Flora in Appendicitis
stageof
Number of
Aerobe
Anaerobe
Sterile
Appendicitis
Children
Present (%)
Present (%)
Culture (%)
Simple
24
38
Suppurative
38
95
5
Gangrenous
12
100
03
Perforated
29
97
100
-
Abscessed
5
100
100
-
Interval
6
17
-
83
114
80
Total
-
42 5 -
19
40
Table 4. Signs, Symptoms, and Peritoneal Flom in 106 Children Undergoing Emergency Appendectomy Bacterioloav
No growth Aerobe
Number of
Duration
Diffuse
Temperature
Children
> 36 hr (%)
Tenderness (%)
> 38’C (%I
17
only present
Anaerobes Total
-
-
Leukocytosis > 13.000/sa
-
1%)
-
45
22
24
13
9
46
09
85
100
90
108
47
46
48
45
Table 5. Postoperative Wound and lntraabdominal Infections stage of
Number of
Wound
Appendicitis
Children
Infection (96)
Simple
24
lntroobdominol
-
Abscess
Suppurative
38
5
3
Gangrenous
12
25
8
Perforated
29
31
10
Abscessed
5
100
40
Interval
6
-
-
Total
114
(%)
-
17
6
Table 6. Peritoneal Flom and Postoperative Infections in 108 Children Undergoing Emergency Appendectomy Bacteriology
Number of
Wound
Children
Infection (%) -
introabdominal Abscess (%) -
No growth
17
Aerobe
45
2
46
39
15
108
18
6
only
Anaerobes
present
Total
Table 7. Postoperative Infections Site of
Number of
Aerobe
Anoerobe
Infection
Children
Present (%)
Present (%)
19
100
89
7
100
100
26
100
92
Wound lntraabdominol Total
40
H.
Toble 8.
HARLAN
Aerobic Bacteria Isolated from Peritoneal Fluid of
91 of 114 Children Undergoing Appendectomy Bacteria
Number
Incidence (%)
Escherichiaco/i
74
81
Klebsiello-Enterobocter
36
40
Proteus
32
35
Pseudomonas oeruginoso
3
3
Miscellaneous gram-negative rods
17
19
Enterococci
27
30
Miscellaneous gram-positive cocci
2
2
Other
2
Total
193
2 -
Table 9. Anaerobic Bacteria Isolated from Peritoneal Fluid of 46 of 114 Children Undergoing Appendectomy Bacteria
Number
Incidence (or61
Bocteroides
44
96
8. frogilis
39
85
&bacteria
21
46
Cfosfridio
17
37
Propionibocferio
16
35
Peptostrepfococci
18
39
Pepfococci
16
35
Miscellaneous
40
07 -
172
Total
Table 10. Aerobic Bacteria Isolated from Postoperative Infections in 21 of 114 Children Undergoing Appendectomy Bacteria
Number
Escherichio co/i
17
Klebsiek-Enterobocter
11
52
8
38
ProfeLls
81
Pseudomonas oeruginoso
1
5
Miscellaneous gram-negative rods
7
33
10
40
Enterococci Miscellaneous gram-positive cocci
1
5
Other
2
10
Total
-
57 Table 11. Anaerobic krcteria Isolated from PostoPemtive Infections in 19 of 114 Children Undergoing Appendectomy Bacteria
NUIlhM
Incidence (%)
Bacteroides
19
8. frogilis
17
89
9
47
Eubocterio Clostridk
100
3
16
Propionibacterio
11
58
Peptostreptococci
11
58
Peptococci
10
53
Miscellaneous
19
100
Total
99
STONE
BACTERIAL
FLORA
41
had a symbiotic infection due to participation by both major groups of organisms. Although no bacterial growth was noted on culture of the peritoneal fluid from 23 of the children, 193 different aerobic isolates were obtained from the remaining 91 cases. This gave an average of 2.1 aerobic species per positive culture. The incidence of anaerobes being present was less, occurring in only 46 of the children. However, 172 different anaerobes were cultured, thereby giving an average of 3.7 anaerobic species per positive culture. The various aerobic and anaerobic isolates are given in Tables 8 and 9, respectively. Similar bacteriologic results with respect to number of species were noted in cultures of postoperative wound and intraabdominal abscesses (Tables 10 and 11). DISCUSSION
Prior studies have correlated the event of appendiceal gangrene and perforation with four easily obtainable parameters: (1) duration of symptoms longer than 36 hr; (2) diffuse abdominal pain and tenderness; (3) temperature over 38°C; and (4) white blood count in excess of 13,OOO/sq mm.6 Parameters (1) and (2) are closely related to the transperitoneal spread of the infectious process, while (3) and (4) reflect contamination of the peritoneal cavity by anaerobic bacteria, which occurs only after gross or microscopic appendiceal perforation. As has been documented by many previous studies as well as reiterated in the present report, infectious complications of appendicitis are primarily sequels to a disease that has progressed to perforation. ‘s6It is not necessary for absolute gross perforation to have occurred; microscopic perforation, i.e., gangrenous appendicitis, can produce an identical inoculation of the peritoneum and surgical incision with almost the same incidence as later infectious complications.6 More critical to the development of postoperative infection, however, is the presence of anaerobic as well as aerobic species.‘s2s5 The polymicrobial flora thereby created are far more virulent and involve a much greater rate of infectious complications than does any aerobic component alone.‘*2*5 The basic treatment of anaerobic sepsis is the conversion of the area of infection to an aerobic environment. Such is accomplished by excision of all necrotic tissue and subsequent exposure of the resultant wound to atmospheric oxygen. Just the brief period during which the abdomen is opened at appendectomy has been shown to reduce dramatically the anaerobic population.2 Nevertheless, if a facultative or even strict aerobe is present in the immediate vicinity of the anaerobic pathogen, the symbiotic support thereby rendered by the aerobic partner can maintain both life and virulence of the anaerobe despite relatively good local perfusion and thus normal oxygen tensions. Under these circumstances the anaerobe can be eradicated by elimination of its aerobic counterpart. Such a mechanism of action readily explains the excellent, though all too often temporary, benefit obtained by an antibiotic effective only against aerobic species in the control of polymicrobial peritoneal sepsis.2 SUMMARY
Aerobic and anaerobic cultures were taken immediately upon operative entry to the peritoneal cavity of 114 consecutive children undergoing appendectomy.
42
H. HARLAN
STONE
Stage of appendicitis and clinical presentation could be closely correlated to specific patterns of peritoneal bacterial flora. It was found that appendiceal gangrene and perforation uniformly produce a polymicrobial peritonitis that is based on the symbiosis of aerobes with anaerobes. Ensuing wound and intraabdominal septic complications were likewise mixed infections. Based on these findings, refinements in the diagnosis of appendiceal gangrene and perforation as well as rationales in the treatment of appendicitis have been discussed. REFERENCES I. Gorbach SL, Bartlett JG: Anaerobic infections. N Engl J Med 290:1177,1237,1269, 1974 2. Stone HH, Kolb LD, Geheber CE: Incidence and significance of intraperitoneal anaerobic bacteria. Ann Surg 181:705, 1975 3. Bauer AW, Kirby WMM, Sherris JC. et al: Antibiotic susceptibility testing by a standardized single disc method. Am J Clin Pathol 45:493, 1966
4. Holdeman LV, Moore WEC: Anaerobe Laboratory Manual. Blacksburg, Va, VP1 Laboratory, 1972 5. Altemeier WA: The bacterial flora of acute perforated appendicitis with peritonitis. Ann Surg 107517, 1938 6. Stone HH, Sanders SL, Martin JD Jr: Perforated appendicitis in children. Surgery 69: 673, 1971
