Piperacillin/tazobactam versus ceftriaxone/metronidazole for children with perforated appendicitis: a systematic review and meta-analysis

PurposeMost children with acute appendicitis are treated with laparoscopic appendectomy followed by antibiotics if the appendix is found to be perforated. There is variation in the type of post-operative antibiotics used for these patients.MethodsWe conducted systematic searches of Medline, Embase, and Cochrane for comparative studies of children with perforated appendicitis treated with post-operative piperacillin/tazobactam versus ceftriaxone and metronidazole.ResultsWe identified four studies consisting of 25,730 children with perforated appendicitis treated with laparoscopic appendectomy followed by post-operative piperacillin/tazobactam (n = 9,950) or ceftriaxone and metronidazole (n = 15,780). One study was a randomized controlled trial (RCT) and three were multicenter observational studies. Meta-analysis suggested no differences between piperacillin/tazobactam and ceftriaxone and metronidazole in terms of deep/organ-space surgical site infection (risk ratio [RR] = 0.97, 95% confidence interval [CI] 0.57–1.65), post-operative imaging (RR = 0.99, 95% CI 0.71–1.37), return to the emergency department (RR = 0.82, 95% CI 0.50–1.37), and readmission to hospital (RR = 0.85, 95% CI 0.45–1.62). Heterogeneity between studies was substantial (I2 73–83%). The RCT was limited by possible ascertainment bias, while the three observational studies may have been affected by baseline differences between treatment groups.ConclusionThis systematic review suggests that there is ongoing uncertainty regarding the optimal post-operative antibiotics for children with perforated appendicitis.Clinical trial registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD42023421492.