Optimizing Antibiotic Management for Adult Patients Presenting with Acute Perforated Appendicitis: A Quality Improvement Study

Introduction: Acute appendicitis (AA) is one of the most common surgically treated diseases, and perforation is a complication that increases morbidity and mortality. At our institution, providers frequently prescribe broad-spectrum antibiotics for patients with appendicitis. Methods: We performed a subset analysis of patients with perforated appendicitis in a multisite quality improvement project to decrease broad-spectrum antibiotic utilization for AA. Surgeons and emergency department providers were educated on antibiotic therapy for AAs. Electronic medical record (EMR) orders were optimized to encourage ceftriaxone plus metronidazole preoperatively and discourage piperacillin/tazobactam. Results: During the study periods, a total of 116 patients had perforated appendicitis and underwent laparoscopic appendectomy, 45 in the 6-month pre-protocol group (pre-AB) and 71 in the 6-month post-protocol group (post-AB). The groups were similar regarding baseline demographics, vital signs, and hematological workup. Preoperative piperacillin/tazobactam utilization rates were 62.2% in the pre-AB group and 25.4% in the post-AB group (p < 0.0001), and the utilization rates of ceftriaxone plus metronidazole were 8.9% and 53.5%, respectively. Thirty-day readmission rates were similar: 15.6% in the pre-AB group versus 5.6% in the post-AB group (p = 0.104). Surgical site infections (SSIs) were comparable among groups: superficial SSI 0.0% versus 2.8% (p = 0.521), deep SSI 4.4% versus 0.0% (p = 0.148), and organ space SSI 17.8% versus 8.5% (p = 0.152). No patient had a Clostridium difficile infection postoperatively. Conclusion: Education regarding antibiotic therapy and optimization of orders in the EMR can decrease the utilization of broad-spectrum antibiotics for acute perforated appendicitis without increasing SSIs.