Background: Conservative treatment of acute appendicitis has become more common in the modern era. However, there has been a paucity of research investigating the need antibiotics on the treatment of early appendicitis, which may just represent appendiceal inflammation rather than true infection.
Methods: This study was conducted at a single center, Sahlgrenska University Hospital in Sweden. Inclusion criteria were patients 18-60 years old with WBC< 13000/uL, CRP<60 mg/L with suspected acute appendicitis on abdominal imaging. Patients were randomized into the treatment arm (early antibiotic with in-hospital observation) or control arm (in-hospital observation without antibiotics). The antibiotic regimen in the study was piperacillin/tazobactam followed by outpatient ciprofloxacin/flagyl for 8-10 days. If there was no improvement in the symptoms within 24-48 hours, the patient was offered an operation. The primary end point was treatment failure with need for appendectomy.
Results: There were 1019 patients identified with early appendicitis, 12.4% of these were eligible for inclusion. 69 patients were placed into the study group, 57 were in the control group. Study patients had a significantly lower risk for needing surgery (28% in study patients versus 53% in control patients, p<.004) during the initial hospital admission. Antibiotics prevented surgical exploration and appendectomy in the study group.
Discussion: Antibiotics versus observation alone reduced the number of operative explorations for appendicitis in this patient population.
Limitations: The major limitation to this study is the low number of patients that were enrolled and met characteristics. The study also did not address any secondary outcomes including adverse reactions to antibiotic therapy or the complexity of operation should they fail antibiotics.
Background: Surgical patients are at high risk for venous thromboembolism (VTE) and this risk is doubled in patients requiring emergent surgical intervention. This risk can be mitigated by 50-70% with VTE prophylaxis. Typically, enoxaparin dosing is only altered for obesity or renal insufficiency, however literature increasingly supports Xa level monitoring for patients to ensure therapeutic drug levels. This has not been examined in the emergency general surgery population.
Methods: This was a single center study examining all EGS patients over 18 years old admitted over a 6-month period. The patients were monitored with anti-factor Xa (goal .3-.5 IU/mL) levels 3-6 hours after the third dose of medication. Those with CKD, AKI, hemorrhage or pregnancy were excluded from the study. Enoxaparin 40mg daily was given for patients with a BMI <40kg/m2, BMI>40kg/m2 were on enoxaparin 40mg BID.
Results: Total of 1220 patients were seen by the EGS service, after application of inclusion criteria 81 patients were enrolled in the study. 75% of those patients received 40mg enoxaparin daily. Upon first evaluation, 88% of patients had anti Xa levels below target range (mean peak was .16IU/mL). Of those with initially low levels, 27% were admitted long enough to undergo dosing adjustment. 82% of these remained below target range despite there being no difference in the demographics between the groups. No patients had a symptomatic VTE in the study. Two patients suffered upper GI bleeds, both were in the low Xa level group.
Discussion: VTE prophylaxis dosing has not been well studied in EGS patients, especially those that are managed nonoperatively. This study found that the majority of EGS patients are underdosed with current dosing protocols.
Limitations: The sample size for this study is very small and due to the length of stay requirements may have selected for more critically ill patients. Authors draw conclusions about but do not discriminate between nonoperatively and operatively managed patients in their analysis, though presumably surgical patients would have a potentially higher risk. This is likely because only 17/81 patients were nonoperatively managed in the study as it was not powered to look at the populations separately. Additionally routine screening for VTEs was not completed in this study.
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