Perforated Appendicitis: Current Experience in
a
Childrens Hospital
MICHAEL B. MARCHILDON, M.D.,* DAVID L. DUDGEON, M.D.t
A review of 89 consecutive cases of perforated appendicitis reFrom the Department of Pediatric Surgery Childrens Hospital of Los Angeles cently treated surgically at Childrens Hospital of Los Angeles Los Angeles, California revealed no mortality and a complication rate of 17%. Significant factors in this low morbidity are: adequate preoperative resuscitation, routine administration of broad spectrum antibiotics pre and postoperatively, and attention to surgical detail. Anaerobic organisms were invariably present in cultures of the peritoneal Los Angeles and their courses reviewed. These 89 cases fluid taken at operation. Anaerobes were also present in the represented 37% of all appendicitis cases treated during blood in all 5 patients having positive blood cultures and were frequently pathogens whenever postoperative infectious complica- this period. All nonperforated appendicitis patients or tions occurred. The use of antibiotics effective against anaerobic patients treated initially at another hospital were exorganisms was common in this series and produced no morbidity. cluded. Nine patients with a protracted clinical history
P ERFORATED APPENDICITIS in children still produces a high morbidity (20-56%) despite a significant decrease in the mortality rate. The high incidence of infectious complications is the major cause of morbidity. Controversy still exists on what management in the preoperative, intraoperative, and postoperative periods is most effective in preventing or controlling infection. We have reviewed the course of patients with perforated appendicitis at Childrens Hospital of Los Angeles managed by standard modes of therapy to determine the morbidity. Material
Eighty-nine consecutive patients with perforated appendicitis occurring between January 1, 1973 to February 28, 1975 were treated initially at Children's Hospital of Submitted for publication March 1, 1976. * Present address: Division of Pediatric Surgery, University of Miami, P.O. Box 520875 Biscayne Annex, Miami, Fla. 33152. t Present address: Division of Pediatric Surgery, Upstate Medical Center, Syracuse, New York. Reprint requests: Michael B. Marchildon, M.D.
84
and suspected perforated appendicitis with an intraperitoneal abscess were treated initially with antibiotics in preparation for a subsequent interval appendectomy. These patients are not included in the present study. Two of three of the following criteria were required to establish a diagnosis of perforated appendicitis: 1) Intraoperative diagnosis of gross perforation; 2) Histologic diagnosis of a microperforation; 3) Presence of enteric organisms in cultured peritoneal fluid. Seventysix (85%) of the 89 patients fulfilled all three criteria. There were 52 males and 37 females, ranging in age from 1½/2 to 17 years. The average age was 7½2 years and only two patients were less than two years old. Perforated appendicitis was correctly diagnosed preoperatively in 62 patients (70%). Delay in diagnosis may have occurred prior to hospital admission but only two patients were hospitalized longer than 48 hours prior to surgery. Intravenous fluids and antibiotics were started in all patients with a preoperative diagnosis of perforated appendicitis. Twenty-seven patients were diagnosed intraoperatively and 4 received antibiotics at that time. All patients received antibiotics in the postoperative period. The antibiotics used in 1973 were Ampicillin
VOl. 185 * NO. I
PERFORATED APPENDICITIS
TABLE 1. Operative Technique: 89 Cases
Peritoneal cavity drained Primary skin closure Delayed primary closure Peritoneal drainage & primary closure Irrigation of peritoneal cavity Inversion of appendical stump
TABLE 3. Bacteriology of Peritoneal Fluid Cultures
No.
%
83 77 12 73 19 86
93% 87% 13% 82% 21% 97%
Aerobic cultures (86) E. coli Pseudomonas Alpha hemolytic streptococcus Enterococcus Anaerobic cultures (46) Bacteroides fragilis Clostridia species
Number
Per Cent
70 30 29 13
83% 37%
43 20
93% 43%
36% 15%
and Kanamycin. In 1974 Gentamycin was substituted for Kanamycin and in this same period of time, Clindamycin was frequently used instead of Ampicillin. The surgeons described localized intra-abdominal abscesses in 68 cases and diffuse peritonitis in 7 cases. In 14 cases the description of the gross pathology was unclear. Various operative techniques (Table 1) were employed but the peritoneal cavity was routinely drained if either a localized abscess or diffuse peritonitis was encountered. The drains were left in place an average of 91/2 days. In 76 patients the drains were brought out through the abdominal incision. The peritoneal cavity was locally irrigated with saline in 21% of the cases but no antibiotic lavage was used. Delayed primary closure of skin and subcutaneous tissues was used in 12 cases and 77 other wounds were closed primarily. The decision as to the operative technique was made by the responsible surgeons involved and not by a protocol.
Table 3 shows the culture results of the peritoneal fluid in these patients. E. coli was the most prevalent aerobic organism and was sensitive to Ampicillin in 81% of the cultures. Anaerobic peritoneal cultures grew Bacteroides fragilis (93%) and clostridia (43%). Mixed anaerobic growth with numerous other organisms was common. Postoperative wound infections (Table 4) were rarely cultured for anaerobic organisms. Five patients has preoperative blood cultures which grew Bacteroides fragilis. One patient had a stool culture obtained just prior to her appendectomy which subsequently grew Shigella. No drug morbidity was associated with the use of Kanamycin (22 patients), Gentamycin (65 patients), or Clindamycin (32 patients) as initial antibiotics. An additional 5 patients received Clindamycin secondarily after having developed an infectious complication. All 5 patients with blood cultures containing Bacteroides were treated with Clindamycin parenterally. The only patient who required Results a reoperation for pelvic and subphrenic abscesses had Bacteroides in both the pre and postoperative blood There were no deaths in this operative series. The cultures and cultured Bacteroides from the subsequent morbidity rate was 17% (15 patients) (Table 2). One subphrenic abscesses. patient required reoperation for pelvic and subphrenic abscesses. Two patients developed pelvic abscesses Discussion which drained spontaneously, one through the vagina Most series report that the incidence of perforated and one through the incision. Four patients had prolonged hospitalizations (14 days) due to fever and a palpable appendicitis, compared to nonperforated, has not depelvic phlegmon which responded to antibiotic therapy. creased.4'14 This high incidence, including our series There were 7 minor wound infections requiring drainage (37%), is probably related to a delay in diagnosis. Perforated appendicitis no longer has a high mortality as a ward procedure. None of these wound infections occurred in patients with delayed primary wound closure. rate and effective antibiotic therapy has contributed TABLE 4. Bacteriology of Complications
TABLE 2. Postoperative Complications
Subphrenic & pelvic abscess, reoperation Pelvic abscess, drained spontaneously Prolonged fever, rectal bogginess Wound infection Right scrotal inflammation
No.
%
1 2 4 7 1
1% 2% 5% 8% 1%
Positive Preop Blood Cultures
Hemolytic streptococcus
Subphrenic Abscess
1/5
1/6
1/1
5/5
1/1
1/1
Bacteroides 15
17%
fragilis
Pelvic Abscess 2/2 1/2
5/6 2/6
E. coli Pseudomonas a
Wound Infections
2/2
86
MARCHILDON AND DUDGEON
significantly to this improvement.4 Another contributing therapeutic measure is an intensive preoperative resuscitative effort of up to 12 hours to improve the condition of these patients who are usually severely hypovolemic and hyperthermic. These latter factors are emphasized in the reduced mortality rate of perforated appendicitis reported by Pledger et al. 12 and also in the reduction of postoperative morbidity.10 The preoperative use of systemic antibiotics, intravenous fluid therapy, and cooling measures to prevent seizures and malignant hyperthemia cannot be overemphasized. Shandling reported a series of perforated appendicitis patients in whom antibiotic therapy was rarely used, with a complication rate of 46%.13 Complications and Antibiotics. The high morbidity rate of perforated appendicitis in most clinical reviews has led to controversy over appropriate therapy including the use and timing of appropriate antibiotics. We favor the use of systemic broad spectrum antibiotics as soon as the diagnosis is clinically suspected or beginning antibiotics intraoperatively if an unsuspected perforation is found. Experimental and clinical evidence supports early antibiotic therapy and questions the effectiveness of delayed institution of these agents."1'4 We have chosen Gentamycin as the most effective agent against the common gram negative pathogens E. coli and Pseudomonas. The monitoring of renal function with twice weekly blood urea nitrogen and creatinine levels has prevented any significant toxicity in our patients. There is strong evidence that preoperative antibiotics reduce the incidence of postoperative intra-abdominal abscesses.14 Many surgeons also favor the use of intraperitoneal drains when the intraperitoneal contamination is localized to the area of the appendix.10 The efficacy of intraperitoneal drains in patients with generalized peritonitis has been questioned.7 Fowler5 reported a reduction in the incidence of postoperative intraperitoneal abscesses (18% to 3%) with the use of intraperitoneal antibiotic lavage for the first 48 hours after surgery. The incidence of wound infections (22%) was unchanged. We have had no experience with this technique. Wound infections appear to be reduced by delayed primary closure of the skin and subcutaneous tissue.6"4 Twelve patients were closed in this manner without a complication, but only 7 minor wound infections developed in 77 patients whose wounds were closed primarily (9.1%). Intraperitoneal drains were brought out the lateral aspect of the incisional site. This may enhance drainage of the subcutaneous space and reduce wound infections.10 There is a reported lower incidence of wound infections in children than in adults with perforated appendicitis. Anaerobic Organisms. The role of anaerobic organisms in postoperative morbidity is still not clear.3'9
Ann. Surg.
January 1977
Leigh has reported an increasing incidence of Bacteroides involvement in post-appendectomy wound infections, reaching 82% in 1971.8 Douglas and Vesey reported that the presence of Bacteroides in peritoneal fluid cultures at the time of appendectomy greatly increases the risk of developing a postoperative infectious complication.2 The presence of Bacteroides fragilis in 93% of the anaerobic cultures taken at surgery and particularly as the organism found in all positive preoperative blood cultures is impressive. Stone15 also found Bacteroides universally present in peritoneal cultures of perforated appendicitis. He detected anaerobic organisms in 2/3 of the postoperative wound and intra-abdominal infections. Bacteroides were found in 2 of 3 of our patients developing pelvic abscesses. Bacteroides has been effectively treated with Clindamycin.3 The reported serious gastrointestinal complications1'16-18'20 did not occur in our patients, but therapy was discontinued in a few patients who demonstrated early signs of diarrhea. Pseudomembranous enterocolitis in children as a complication of Clindamycin therapy has not been reported following parental administration of this drug. Pseudomembranous enterocolitis has been reported as a complication of antibiotic therapy with a number of other antibiotic agents, including Ampicillin. Either Ampicillin or Clindamycin was used in all our patients. No statistical difference could be demonstrated if Clindamycin was used; however, the incidence of complications was too low to make a precise comparison. The use of Clindamycin may be indicated since our major infectious complications all involved Bacteroides, and we have had no morbidity that can be attributed to the use of Clindamycin. This is also supported by a prospective study of infectious complications due to bowel contamination reported by Thadepalli et al. 19 Stone, however, could not show improved morbidity when comparing Clindamycin to Keflin.15 Clindamycin does not adequately treat enterococcus, and penicillin should be considered as part of the antibiotic regimen. This series of 89 consecutive patients has had a very low morbidity rate (17%). We feel the decreased morbidity is attributable to the following factors: 1) Adequate preoperative resuscitation consisting of intravenous fluids, appropriate systemic antibiotics often including agents for anaerobic organisms, and extensive cooling procedures. 2) Routine use of intraperitoneal drainage, localized saline lavage, and the intraoperative administration of appropriate parenteral antibiotics in the unsuspected perforation. References 1. Alexander, J. W. and Altemeier, W. A.: Penicillin Prophylaxis of
Experimental Staphylococcal Wound Infections. Surg. Gynecol. Obstet., 120:243, 1965. 2. Douglas, B., and Vesey, B.: Bacteroides: A Cause of Residual Abscess? J. Ped. Surg., 10:215, 1975.
Vol. 185 . No.
PERFORATED APPENDICITIS
3. Finegold, S. M.: Treatment of Anaerobic Infections. N. Engl. J. Med., 290:1323, 1974. 4. Fowler, R.: Childhood Mortality from Acute Appendicitis: The Impact of Antibiotics. Med. J. Australia, 2:1009, 1971. 5. Fowler, R.: A Controlled Trial of Intraperitoneal Cephaloridine Administration in Peritonitis. J. Ped. Surg., 10:43, 1975. 6. Grosfeld, J. L. and Solit, R. W.: Prevention of Wound Infection in Perforated Appendicitis; Experience with Delayed Primary Wound Closure. Ann. Surg., 168:891, 1968. 7. Haller, J. A., Shaker, I. J., Donahoo, J. S., et al.: Peritoneal Drainage Versus Non-drainage for Generalized Peritonitis from Ruptured Appendicitis in Children. Ann. Surg., 177:595, 1973. 8. Leigh, D. A.: Bacteroides Infections. Letter to editor, Lancet, 2: 1081, 1973. 9. Moore, W. E. C., Cato, E. P., and Holdeman, L. V.: Anaerobic Bacteria of the Gastrointestinal Flora and Their Occurrence in Clinical Infections. J. Infect. Dis., 119:641, 1969. 10. Othersen, H. B. and Campbell, T. W.: Programmed Treatment of Ruptured Appendicitis in Children. South. Med. J., 67:903, 1974. 11. Page, M. I.: Beware-The Anaerobe Bandwagon. N. EngI. J. Med., 290:338, 1974.
87
12. Pledger, H. G. and Buchan, R.: Deaths in Children with Acute Appendicitis. Br. Med. J., 4:466, 1969. 13. Shandling, B., Ein, S. H., Simpson, J. S., et al.: Perforating Appendicitis and Antibiotics. J. Ped. Surg., 9:79, 1974. 14. Stone, H. H., Sanders, S. L. and Martin, J. D., Jr.: Perforated Appendicitis in Children. Surgery, 69:673, 1971. 15. Stone, H. S., Kolb, L. D. and Geleber, C. E.: Incidence and Significance of Intraperitoneal Anaerobic Bacteria. Ann. Surg., 181:705, 1975. 16. Stroehlein, J. R., Sedlack, R. E., Hoffmann, H. N., et al.: Clindamycin Associated Colitis. Mayo Clin. Proc., 49:240, 1974. 17. Tedesco, F. J., Stanely, R. J. and Alpers, D. H.: Diagnostic Features of Clindamycin Associated Pseudomembranous Colitis. N. Engl. J. Med., 290:841, 1974. 18. Tedesco, F. J., Barton, R. W. and Alpers, D. H.: Clindamycin Associated Pseudomembranous Colitis: A Prospective Study. Ann. Intern. Med., 81:429, 1974. 19. Thadepalli, H., Gorbach, S. L., Broido, P. W., et al.: Abdominal Trauma, Anaerobes, and Antibiotics. Surg. Gynecol. Obstet., 137:270, 1973. 20. Viteri, A. L., Howard, P. H. and Dyck, W. P.: The Spectrum of Lincomycin-clindamycin Colitis. Gastroenterology, 66:1137, 1974.
a
Childrens Hospital
MICHAEL B. MARCHILDON, M.D.,* DAVID L. DUDGEON, M.D.t
A review of 89 consecutive cases of perforated appendicitis reFrom the Department of Pediatric Surgery Childrens Hospital of Los Angeles cently treated surgically at Childrens Hospital of Los Angeles Los Angeles, California revealed no mortality and a complication rate of 17%. Significant factors in this low morbidity are: adequate preoperative resuscitation, routine administration of broad spectrum antibiotics pre and postoperatively, and attention to surgical detail. Anaerobic organisms were invariably present in cultures of the peritoneal Los Angeles and their courses reviewed. These 89 cases fluid taken at operation. Anaerobes were also present in the represented 37% of all appendicitis cases treated during blood in all 5 patients having positive blood cultures and were frequently pathogens whenever postoperative infectious complica- this period. All nonperforated appendicitis patients or tions occurred. The use of antibiotics effective against anaerobic patients treated initially at another hospital were exorganisms was common in this series and produced no morbidity. cluded. Nine patients with a protracted clinical history
P ERFORATED APPENDICITIS in children still produces a high morbidity (20-56%) despite a significant decrease in the mortality rate. The high incidence of infectious complications is the major cause of morbidity. Controversy still exists on what management in the preoperative, intraoperative, and postoperative periods is most effective in preventing or controlling infection. We have reviewed the course of patients with perforated appendicitis at Childrens Hospital of Los Angeles managed by standard modes of therapy to determine the morbidity. Material
Eighty-nine consecutive patients with perforated appendicitis occurring between January 1, 1973 to February 28, 1975 were treated initially at Children's Hospital of Submitted for publication March 1, 1976. * Present address: Division of Pediatric Surgery, University of Miami, P.O. Box 520875 Biscayne Annex, Miami, Fla. 33152. t Present address: Division of Pediatric Surgery, Upstate Medical Center, Syracuse, New York. Reprint requests: Michael B. Marchildon, M.D.
84
and suspected perforated appendicitis with an intraperitoneal abscess were treated initially with antibiotics in preparation for a subsequent interval appendectomy. These patients are not included in the present study. Two of three of the following criteria were required to establish a diagnosis of perforated appendicitis: 1) Intraoperative diagnosis of gross perforation; 2) Histologic diagnosis of a microperforation; 3) Presence of enteric organisms in cultured peritoneal fluid. Seventysix (85%) of the 89 patients fulfilled all three criteria. There were 52 males and 37 females, ranging in age from 1½/2 to 17 years. The average age was 7½2 years and only two patients were less than two years old. Perforated appendicitis was correctly diagnosed preoperatively in 62 patients (70%). Delay in diagnosis may have occurred prior to hospital admission but only two patients were hospitalized longer than 48 hours prior to surgery. Intravenous fluids and antibiotics were started in all patients with a preoperative diagnosis of perforated appendicitis. Twenty-seven patients were diagnosed intraoperatively and 4 received antibiotics at that time. All patients received antibiotics in the postoperative period. The antibiotics used in 1973 were Ampicillin
VOl. 185 * NO. I
PERFORATED APPENDICITIS
TABLE 1. Operative Technique: 89 Cases
Peritoneal cavity drained Primary skin closure Delayed primary closure Peritoneal drainage & primary closure Irrigation of peritoneal cavity Inversion of appendical stump
TABLE 3. Bacteriology of Peritoneal Fluid Cultures
No.
%
83 77 12 73 19 86
93% 87% 13% 82% 21% 97%
Aerobic cultures (86) E. coli Pseudomonas Alpha hemolytic streptococcus Enterococcus Anaerobic cultures (46) Bacteroides fragilis Clostridia species
Number
Per Cent
70 30 29 13
83% 37%
43 20
93% 43%
36% 15%
and Kanamycin. In 1974 Gentamycin was substituted for Kanamycin and in this same period of time, Clindamycin was frequently used instead of Ampicillin. The surgeons described localized intra-abdominal abscesses in 68 cases and diffuse peritonitis in 7 cases. In 14 cases the description of the gross pathology was unclear. Various operative techniques (Table 1) were employed but the peritoneal cavity was routinely drained if either a localized abscess or diffuse peritonitis was encountered. The drains were left in place an average of 91/2 days. In 76 patients the drains were brought out through the abdominal incision. The peritoneal cavity was locally irrigated with saline in 21% of the cases but no antibiotic lavage was used. Delayed primary closure of skin and subcutaneous tissues was used in 12 cases and 77 other wounds were closed primarily. The decision as to the operative technique was made by the responsible surgeons involved and not by a protocol.
Table 3 shows the culture results of the peritoneal fluid in these patients. E. coli was the most prevalent aerobic organism and was sensitive to Ampicillin in 81% of the cultures. Anaerobic peritoneal cultures grew Bacteroides fragilis (93%) and clostridia (43%). Mixed anaerobic growth with numerous other organisms was common. Postoperative wound infections (Table 4) were rarely cultured for anaerobic organisms. Five patients has preoperative blood cultures which grew Bacteroides fragilis. One patient had a stool culture obtained just prior to her appendectomy which subsequently grew Shigella. No drug morbidity was associated with the use of Kanamycin (22 patients), Gentamycin (65 patients), or Clindamycin (32 patients) as initial antibiotics. An additional 5 patients received Clindamycin secondarily after having developed an infectious complication. All 5 patients with blood cultures containing Bacteroides were treated with Clindamycin parenterally. The only patient who required Results a reoperation for pelvic and subphrenic abscesses had Bacteroides in both the pre and postoperative blood There were no deaths in this operative series. The cultures and cultured Bacteroides from the subsequent morbidity rate was 17% (15 patients) (Table 2). One subphrenic abscesses. patient required reoperation for pelvic and subphrenic abscesses. Two patients developed pelvic abscesses Discussion which drained spontaneously, one through the vagina Most series report that the incidence of perforated and one through the incision. Four patients had prolonged hospitalizations (14 days) due to fever and a palpable appendicitis, compared to nonperforated, has not depelvic phlegmon which responded to antibiotic therapy. creased.4'14 This high incidence, including our series There were 7 minor wound infections requiring drainage (37%), is probably related to a delay in diagnosis. Perforated appendicitis no longer has a high mortality as a ward procedure. None of these wound infections occurred in patients with delayed primary wound closure. rate and effective antibiotic therapy has contributed TABLE 4. Bacteriology of Complications
TABLE 2. Postoperative Complications
Subphrenic & pelvic abscess, reoperation Pelvic abscess, drained spontaneously Prolonged fever, rectal bogginess Wound infection Right scrotal inflammation
No.
%
1 2 4 7 1
1% 2% 5% 8% 1%
Positive Preop Blood Cultures
Hemolytic streptococcus
Subphrenic Abscess
1/5
1/6
1/1
5/5
1/1
1/1
Bacteroides 15
17%
fragilis
Pelvic Abscess 2/2 1/2
5/6 2/6
E. coli Pseudomonas a
Wound Infections
2/2
86
MARCHILDON AND DUDGEON
significantly to this improvement.4 Another contributing therapeutic measure is an intensive preoperative resuscitative effort of up to 12 hours to improve the condition of these patients who are usually severely hypovolemic and hyperthermic. These latter factors are emphasized in the reduced mortality rate of perforated appendicitis reported by Pledger et al. 12 and also in the reduction of postoperative morbidity.10 The preoperative use of systemic antibiotics, intravenous fluid therapy, and cooling measures to prevent seizures and malignant hyperthemia cannot be overemphasized. Shandling reported a series of perforated appendicitis patients in whom antibiotic therapy was rarely used, with a complication rate of 46%.13 Complications and Antibiotics. The high morbidity rate of perforated appendicitis in most clinical reviews has led to controversy over appropriate therapy including the use and timing of appropriate antibiotics. We favor the use of systemic broad spectrum antibiotics as soon as the diagnosis is clinically suspected or beginning antibiotics intraoperatively if an unsuspected perforation is found. Experimental and clinical evidence supports early antibiotic therapy and questions the effectiveness of delayed institution of these agents."1'4 We have chosen Gentamycin as the most effective agent against the common gram negative pathogens E. coli and Pseudomonas. The monitoring of renal function with twice weekly blood urea nitrogen and creatinine levels has prevented any significant toxicity in our patients. There is strong evidence that preoperative antibiotics reduce the incidence of postoperative intra-abdominal abscesses.14 Many surgeons also favor the use of intraperitoneal drains when the intraperitoneal contamination is localized to the area of the appendix.10 The efficacy of intraperitoneal drains in patients with generalized peritonitis has been questioned.7 Fowler5 reported a reduction in the incidence of postoperative intraperitoneal abscesses (18% to 3%) with the use of intraperitoneal antibiotic lavage for the first 48 hours after surgery. The incidence of wound infections (22%) was unchanged. We have had no experience with this technique. Wound infections appear to be reduced by delayed primary closure of the skin and subcutaneous tissue.6"4 Twelve patients were closed in this manner without a complication, but only 7 minor wound infections developed in 77 patients whose wounds were closed primarily (9.1%). Intraperitoneal drains were brought out the lateral aspect of the incisional site. This may enhance drainage of the subcutaneous space and reduce wound infections.10 There is a reported lower incidence of wound infections in children than in adults with perforated appendicitis. Anaerobic Organisms. The role of anaerobic organisms in postoperative morbidity is still not clear.3'9
Ann. Surg.
January 1977
Leigh has reported an increasing incidence of Bacteroides involvement in post-appendectomy wound infections, reaching 82% in 1971.8 Douglas and Vesey reported that the presence of Bacteroides in peritoneal fluid cultures at the time of appendectomy greatly increases the risk of developing a postoperative infectious complication.2 The presence of Bacteroides fragilis in 93% of the anaerobic cultures taken at surgery and particularly as the organism found in all positive preoperative blood cultures is impressive. Stone15 also found Bacteroides universally present in peritoneal cultures of perforated appendicitis. He detected anaerobic organisms in 2/3 of the postoperative wound and intra-abdominal infections. Bacteroides were found in 2 of 3 of our patients developing pelvic abscesses. Bacteroides has been effectively treated with Clindamycin.3 The reported serious gastrointestinal complications1'16-18'20 did not occur in our patients, but therapy was discontinued in a few patients who demonstrated early signs of diarrhea. Pseudomembranous enterocolitis in children as a complication of Clindamycin therapy has not been reported following parental administration of this drug. Pseudomembranous enterocolitis has been reported as a complication of antibiotic therapy with a number of other antibiotic agents, including Ampicillin. Either Ampicillin or Clindamycin was used in all our patients. No statistical difference could be demonstrated if Clindamycin was used; however, the incidence of complications was too low to make a precise comparison. The use of Clindamycin may be indicated since our major infectious complications all involved Bacteroides, and we have had no morbidity that can be attributed to the use of Clindamycin. This is also supported by a prospective study of infectious complications due to bowel contamination reported by Thadepalli et al. 19 Stone, however, could not show improved morbidity when comparing Clindamycin to Keflin.15 Clindamycin does not adequately treat enterococcus, and penicillin should be considered as part of the antibiotic regimen. This series of 89 consecutive patients has had a very low morbidity rate (17%). We feel the decreased morbidity is attributable to the following factors: 1) Adequate preoperative resuscitation consisting of intravenous fluids, appropriate systemic antibiotics often including agents for anaerobic organisms, and extensive cooling procedures. 2) Routine use of intraperitoneal drainage, localized saline lavage, and the intraoperative administration of appropriate parenteral antibiotics in the unsuspected perforation. References 1. Alexander, J. W. and Altemeier, W. A.: Penicillin Prophylaxis of
Experimental Staphylococcal Wound Infections. Surg. Gynecol. Obstet., 120:243, 1965. 2. Douglas, B., and Vesey, B.: Bacteroides: A Cause of Residual Abscess? J. Ped. Surg., 10:215, 1975.
Vol. 185 . No.
PERFORATED APPENDICITIS
3. Finegold, S. M.: Treatment of Anaerobic Infections. N. Engl. J. Med., 290:1323, 1974. 4. Fowler, R.: Childhood Mortality from Acute Appendicitis: The Impact of Antibiotics. Med. J. Australia, 2:1009, 1971. 5. Fowler, R.: A Controlled Trial of Intraperitoneal Cephaloridine Administration in Peritonitis. J. Ped. Surg., 10:43, 1975. 6. Grosfeld, J. L. and Solit, R. W.: Prevention of Wound Infection in Perforated Appendicitis; Experience with Delayed Primary Wound Closure. Ann. Surg., 168:891, 1968. 7. Haller, J. A., Shaker, I. J., Donahoo, J. S., et al.: Peritoneal Drainage Versus Non-drainage for Generalized Peritonitis from Ruptured Appendicitis in Children. Ann. Surg., 177:595, 1973. 8. Leigh, D. A.: Bacteroides Infections. Letter to editor, Lancet, 2: 1081, 1973. 9. Moore, W. E. C., Cato, E. P., and Holdeman, L. V.: Anaerobic Bacteria of the Gastrointestinal Flora and Their Occurrence in Clinical Infections. J. Infect. Dis., 119:641, 1969. 10. Othersen, H. B. and Campbell, T. W.: Programmed Treatment of Ruptured Appendicitis in Children. South. Med. J., 67:903, 1974. 11. Page, M. I.: Beware-The Anaerobe Bandwagon. N. EngI. J. Med., 290:338, 1974.
87
12. Pledger, H. G. and Buchan, R.: Deaths in Children with Acute Appendicitis. Br. Med. J., 4:466, 1969. 13. Shandling, B., Ein, S. H., Simpson, J. S., et al.: Perforating Appendicitis and Antibiotics. J. Ped. Surg., 9:79, 1974. 14. Stone, H. H., Sanders, S. L. and Martin, J. D., Jr.: Perforated Appendicitis in Children. Surgery, 69:673, 1971. 15. Stone, H. S., Kolb, L. D. and Geleber, C. E.: Incidence and Significance of Intraperitoneal Anaerobic Bacteria. Ann. Surg., 181:705, 1975. 16. Stroehlein, J. R., Sedlack, R. E., Hoffmann, H. N., et al.: Clindamycin Associated Colitis. Mayo Clin. Proc., 49:240, 1974. 17. Tedesco, F. J., Stanely, R. J. and Alpers, D. H.: Diagnostic Features of Clindamycin Associated Pseudomembranous Colitis. N. Engl. J. Med., 290:841, 1974. 18. Tedesco, F. J., Barton, R. W. and Alpers, D. H.: Clindamycin Associated Pseudomembranous Colitis: A Prospective Study. Ann. Intern. Med., 81:429, 1974. 19. Thadepalli, H., Gorbach, S. L., Broido, P. W., et al.: Abdominal Trauma, Anaerobes, and Antibiotics. Surg. Gynecol. Obstet., 137:270, 1973. 20. Viteri, A. L., Howard, P. H. and Dyck, W. P.: The Spectrum of Lincomycin-clindamycin Colitis. Gastroenterology, 66:1137, 1974.
