Optimization of the medical management of appendicular abscess and plastron in children: a 2009 to 2019 cohort study

Optimization of the medical management of appendicular abscess and plastron in children: a 2009 to 2019 cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Optimization of the medical management of appendicular abscess and plastron in children: a 2009 to 2019 cohort study Laily Sadozai, Taieb Chouikh, Henri Kotobi, Benjamin Rossi, Bernadette Coret-Houbart, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1975554/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: In our hospital, children with appendicular plastron or abscess receive a medical treatment with cefotaxime, metronidazole and gentamicin followed by amoxicillin/clavulanic acid as an oral switch. Appendectomy is performed 10 to 12 weeks after the beginning of the discharge. A high failure rate was noticed with a switch to a second line treatments, rehospitalization or an emergency surgery. The objective of our study was to highlight predictive factors for the treatment response. Methods: We conducted a retrospective monocentric study between 2009 and 2019. Inclusion criteria were children under 16 years old diagnosed with appendicular plastron or abscess, treated with a medical treatment. We divided the cohort into a success and a failure group and compared their demographic data, clinical symptoms, inflammatory markers, abdominal imaging and antibiotic regimen. Results: Seventy-four patients were enrolled in the study and the failure rate was 36% (n=27). The median age in the success group was 8.7 years old (2-14) and 9.4 years old (2-15) in the failure group. Multiple abscesses (6.5% versus 32%, p=0.02) and diarrhea at admission (19% versus 44%, p=0.02) were significantly associated with a failure. Palpable mass (47% versus 67%, p=0.09) and stercoliths (34% versus 52%, p=0.13) appeared to be more important in the failure group. Discussion and conclusion: Several factors were analyzed to predict the response to the medical treatment for children with appendicular abscess or plastron. Patients with multiple abscesses will no longer be treated with antibiotics. We also recommended greater vigilance after detecting stercoliths in the medical imaging based on other studies results. Time to hospitalization, time to apyrexia, CRP and white blood cells level at admission were not different between the success and the failure group. Finally, a wider bacterial epidemiology study is needed in order to adjust our local guidelines and the antibiotic therapy. perforated appendicitis abscess antibiotic children Figures Figure 1 Figure 2 Figure 3 Background Appendicitis is an acute inflammation of the appendix and is a common surgical disease of children. It is classified as complicated or uncomplicated depending on the extent of the infection. The incidence of the perforation of the appendix has been reported from 19% to 57% (1,2). In case of isolated appendicitis without any perforation of the appendix: the treatment is based on an emergency appendectomy or in some cases on a conservative treatment with antibiotics (3–8). In case of a peritonitis due to a perforated appendicitis, the treatment is also based on a surgery with a peritoneal lavage (9–13). However, the perforation of the appendix can be circumscribed and evolve to an abscess or a plastron. Currently, no appropriate guidelines have been made for the management of children with appendicular plastron or abscess especially for the surgical approach, the antibiotic therapy, time to the appendectomy, the diagnostic aspect, etc. Several studies showed that the medical treatment with antibiotics followed by an interval appendectomy was effective and could reduce post-operative complications. Indeed, remote surgical management is optimal to avoid intraoperative complications (small bowel wound, ileo-caecal resection, and stoma) and postoperative complications (flange occlusion, wall abscess) (14–23). Failures of the medical treatment of complicated appendicitis is poorly described in the literature and can lead to serious consequences for the patients (24,25). The aim of this study was to attempt to identify predictive factors of success or failure of the initial antibiotic treatment. Material and method Study population : We conducted a retrospective single-center study between January 2009 until December 2019 in a primary care center regional hospital. We included all patients under 16 years old, hospitalized in the pediatric surgery unit and diagnosed with appendicular abscess or plastron. The protocol of the pediatric surgery unit of our hospital was based on a conservative treatment for children presenting symptoms for 3 days or more. This conservative treatment included an intravenous broad-spectrum prophylactic antibiotic therapy with: cefotaxime, metronidazole and gentamicin followed by an oral antibiotic therapy (amoxicillin/clavulanic acid) for a total duration of 2 weeks. Finally, an interval appendectomy was scheduled 10 to 12 weeks after the discharge. We defined a failure to the medical treatment as a patient who had at least one of the three criteria. The first one was a failure to the first line of antibiotics (cefotaxime, metronidazole and gentamicine) requiring a switch to a second line (piperacillin/tazobactam and amikacine). Sometimes a third line of antibiotics was considered. This is assessed on a case-by-case basis with the prescription of carbapenem, cefepime or vancomycin, etc. The second criterion was a sudden recurrence of the symptoms occurring between the discharge and the date of the scheduled appendectomy. In the event of a relapse, the patient received a new course of intravenous antibiotics during the hospitalization. The final criterion of failure was an unscheduled emergency appendectomy. All patients performed an ultrasound scan as a first-line protocol and a CT scan if needed. Children with symptoms for less than 3 days had an appendectomy and were excluded from the cohort. We also excluded all the children with generalized peritonitis as well as the children who started the intravenous antibiotic therapy in another hospital center. Ethical approval for this study was obtained from the local ethic committee of the Robert Debre hospital, Paris, France (number 2021/590bis). Study design: We divided the cohort into a success and a failure group in order to compare different type of data. Study variables: We collected demographic, drug, clinical, biological, medical imaging and surgical data. Information for patients hospitalized between 2012 and 2019 were collected from electronic medical records while patients hospitalized between 2009 and 2011 had their information in both paper and electronic medical records. We extracted clinical symptoms at the admission of the patient at the emergency department. Those clinical symptoms were the presence of fever, digestive disorders, vomiting and the presence of a palpable plastron. Biological markers related to inflammation were collected such as the C-reactive protein (CRP) and white blood cells count. Then, we extracted the bacterial identification in the blood culture and the biological samples. For the medical imaging we analyzed the ultrasound and pelvic abdominal scan records. The following information were collected: whether an ultrasound or a scan were performed, the presence of an abscess or a plastron, the size of the abscess, the presence of a single or multiple abscesses, the presence of a stercolith, the size of the appendix, the presence of an effusion in the right iliac fossa or in the pouch of Douglas. Drug data analyzed were drug taken before the hospitalization, the antibiotic therapy prescribed, the dose, the frequency of administration, the route of administration, the duration of the antibiotic therapy, the delay from the beginning of the hospitalization and the prescription as a first, second- or third-line treatment. Statistical analysis: Statistical tests were carried out using SAS® software (version 9.4). Categorical variables are expressed as N (%) and quantitative variables are expressed as median (min-max). The data for the success versus failure group were compared using the Chi2 test for categorical variables with numbers greater than 5 and a Fisher test for the opposite case. For the comparison of quantitative variables within the two groups, a Mann-Whitney test was performed. Values were considered significant when the p-value was less than 0.05. Results Demographic data: Between 2009 and 2019, 74 patients were diagnosed with an appendicular abscess or plastron and were treated with intravenous antibiotics (see figure 1 ). The number of patients diagnosed with appendicular abscess treated with intravenous antibiotics varied each year with a minimum of 1 and up to 11 (see table 1 ). Table 1: Evolution of the number of successes and failures to the medical treatment from 2009 to 2019 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 1 (100 %) 4 (80%) 7 (64%) 2 (67%) 6 (67%) 0 (0%) 5 (100%) 4 (50%) 6 (55%) 6 (60%) 6 (75%) 0 (0%) 1 (20%) 4 (36%) 1 (33%) 3 (33%) 3 (100%) 0 (0%) 4 (50%) 5 (45%) 4 (40%) 2 (25%) 1 5 11 3 9 3 5 8 11 10 8 Patients included in the success group (n = 47, 64%) and the failure group (n = 27, 36%) were respectively aged 8.7 years old (2-14) and 9.4 years old (2-15) (p = 0.43) (see table 2 ). Length of hospitalization stay was significantly different between the two groups: 8 (5-12) in the success group compared to 15 days (6-29) in the failure group (p < 0.0001). Table 2: Demographic, clinical and imaging description of the patients included in the study Data expressed in n (%) or median (min-max) Successes Failures p-value N 47 (64 %) 27 (36 %) - Gender Male 26 (55 %) 13 (48 %) 0,55 Female 21 (45 %) 14 (52 %) 0,55 Age (years old) 8,7 (2-14) 9,4 (2-15) 0,43 Weight (kg) 30,9 (12,5-69) 30,6 (11-68) 0,36 Duration of symptoms before admission (days) 5 (2-15) 4,85 (3-10) 0,97 Antibiotic(s) before admission 6 (13 %) 7 (26 %) 0,21 NSAI before admission 2 (4 %) 2 (7 %) 0,62 Lenght of hospitalization stay (days) 7,9 (5-12) 14,9 (6-29) < 0,0001 Total duration of antibiotherapy (days) 13,2 (5-21) 18,8 (7-45) 0,016 Clinical signs at the admission Vomiting 27 (57 %) 18 (67 %) 0,43 Diarrhea/liquid stools 9 (19 %) 12 (44 %) 0,02 Palpable mass 22 (47 %) 18 (67 %) 0,09 Fever 36 (77 %) 21 (78 %) 0,91 Intestinal occlusion 3 (6,4 %) 3 (11 %) 0,66 Medical imaging Plastron 16 (34 %) 5 (19 %) 0,15 Abscess 31 (66 %) 22 (81 %) 0,15 - Simple abscess 29 (93,5 %) 15 (68 %) 0,02 - Multiple abscesses 2 (6,5 %) 7 (32 %) 0,02 Stercolith 16 (34 %) 14 (52 %) 0,13 Other medications received before admission: In our cohort, 6 (13%) patients of the success group were treated with antibiotics before the admission with amoxicillin (n = 2), amoxicillin/clavulanic acid (n = 1), cefixime (n = 1) or cefpodoxime (n = 1). Two patients (4%) also received non-steroidal anti-inflammatory drug. In the failure group, 7 (26%) patients were also treated with antibiotics such as: amoxicillin (n = 4), cefpodoxime (n = 1) or ceftriaxone (n = 1, for a suspected acute gastroenteritis with Salmonella spp .) Clinical symptoms: Among all the clinical signs, a significant difference was found in the number of children with diarrhea and loose stools in the failure group at admission (p = 0.02). A trend towards a predominance of palpable mass was also observed in this group (n success = 22 (47%) and n failure = 18 (67%), p = 0.09). Medical imaging: Of the 53 patients with abscess, 44 (83%) had a single abscess and 9 (17%) were multiple. Multiple abscesses were more likely to escape the medical treatment (7/9, 78%) compared to single abscesses (15/44, 34%) (p=0.02). Finally, 30 (40.5%) of the patients had stercoliths: 14 (52%) in the failure group and 16 (34%) in the success group. However, this trend was not statistically significant between the two groups (p = 0.13). Biological values: At the admission, the CRP level was slightly higher in the failure group (157.4 mg/L [55-341]) than in the success group (131.7 mg/L [9-386]) (p = 0.22) (see figure 2 ). On the second biological check-up (S2) - i.e., at day 3 [1-9] - it was not possible to dissociate one group from the other (n success = 99.4 mg/L, n failure = 94.8 mg/L, p = 0.43). The 3 rd biological check-up - i.e. at day 6 [3-10] – was the tipping point to distinguish whether the medical management was effective or not because the CRP rate fell by an average of 33% in the success group while it was stable or increasing in the failure group (p = 0.0038). The figure 3 representing the white blood cell count showed that the values for the first and second biological check-up were not significantly different between the two groups. There was a clear difference between the two group at the third biological check-up (S3) - i.e. at day 6 [3-10] - with a decrease of the values in the success group (10.9 G/L [3.6-21.3]) and an increase in the failure group (15.1 G/L [5.3-28.5]) (p = 0.0018). Finally, only 17 (23%) patients had a documented infection with bacteria growing in their biological samples. The main bacteria found were strict anaerobic bacteria, Escherichia coli and Streptococcus spp . Discussion The management of children with appendicular abscess remains controversial as there is no consensus regarding the guidelines. Several studies proved that conservative treatment with antibiotics could ease and optimize a delayed surgery. The meta-analysis by Similis et al. included 17 randomized and non-randomized studies comparing immediate surgery with conservative treatment (14). The complications were significantly higher after an immediate appendectomy: bowel obstruction, deep abdominal or pelvic abscesses and wound infections. This result was then confirmed by the recent meta-analysis by Vaos et al. and by other studies (15,16,18,21,26). The medical management was interesting by reducing post-operative complications (14). Still, the success of this medical protocol was not entirely guaranteed. Depending on the study, the success rate varied between 74 and 92% (24,27,28). The success rate of our study was lower with 64% of our cohort. The definition of non-response to the medical treatment was quite different from one study to another. Indeed, in our study, the failure criteria were broader as we included all patients for whom the first line of treatment was not effective enough and who therefore required a change in the antibiotic therapy (which is not the cause of most of the similar studies), re-hospitalization or an unscheduled surgery. The failure of the treatment could lead to serious consequences: prolonged hospitalization, parental anxiety and sometimes treatment impasses. For example, one patient of our cohort received a total course of 21 days of intravenous antibiotics with cefotaxime, metronidazole and gentamicin until day 7, piperacillin/tazobactam and amikacin until day 14 and finally ceftazidime, metronidazole and vancomycin until day 21. At the end, the patient was still not responding to the antibiotics with growing abscesses and clinical deterioration. In our hospital, this patient was not eligible for a surgery as it is not recommended after one week of hospitalization because of the adherences and the strong risks of surgery complications. This highlight the importance of early identification of patients who may not respond to the medical treatment and who may benefit from a surgery during the first week of hospitalization. Early identification of those patients is a real challenge. Some predictive factors were analyzed in previous studies as well as in our study (27,29,29,30). First of all, the two groups of our cohort showed no major differences of the CRP and the white blood cell levels at admission. We paid particular attention to the dynamics of the CRP and the with blood cells, all along the hospitalization. We observed that one week was needed to differentiate a patient who is not responding to the medical treatment with a stabilization or an increase of the inflammatory markers. This highlight the fact that it is crucial to find other early predictive factors in order to adjust the treatment sooner, during the first week of hospitalization. Children with multiple abscesses and diarrhea had statistically more failures than others. This is the first study to conclude with an exclusion of the children with multiple abscesses from the conservative treatment. Then, the presence of stercoliths was not significantly associated with failure, even though there was a trend. This contradict the results of other studies, probably due to the number of patients included or the study design (29,31–33). Indeed, in retrospective studies, it is not impossible that the presence or absence of stercoliths was not systematically specified by the radiologists when writing the report, making the analysis less reliable. However, we can recommend greater vigilance in the follow-up after detecting stercoliths in the medical imaging. We also observed more frequent palpable masses during the clinical examination of patients for whom the first line treatment was not effective – probably because of the size of the collection. Finally, time to apyrexia and time to hospitalization did not influence the complexity of the patient’s management in our cohort. It seemed that these two criteria, although logical, did not allow us to identify groups at risk of failure. The main limitation of our study was the retrospective nature which may lead to bias, but also the small number of patients included. Thus, the lack of power due to the small number of data did not allow us to show any significant differences for some criteria between the two groups although some trends was observed. Indeed, for example, the bacteria causing appendicular abscess were rarely documented but the main germs found in the few samples of our cohort were strict anaerobic bacteria, Escherichia coli or Streptococcus spp . This results were similar to other studies (34,35). However, these results cannot be interpreted as the drainage was done after the initiation of the antibiotic therapy and because of the small number of documented infections. The choice of the antibiotic therapy should be assessed as it could be one of many reasons leading to the failure. The hypothesis raised here is that the first line of the antibiotic therapy may not cover the majority of the bacteria causing pediatric digestive infections in our sector. In the future, a wider bacterial epidemiology study is needed to complete our results and to fully adjust our local guidelines and the antibiotic therapy for children with appendicular abscess or plastron. Conclusion The management of children with appendicular abscess and plastron remains controversial and is different from one hospital to another. Many studies proved the benefits of the medical treatment although a significant rate of failures has been observed in our hospital from 2009 until 2019. Several factors were analyzed to predict the response to the medical treatment. Patients with multiple abscesses will no longer be treated with antibiotics. We also recommended greater vigilance after detecting stercoliths in the medical imaging based on other studies results. Time to hospitalization, time to apyrexia, CRP and white blood cells level at admission were not different between the success and the failure group. Finally, a wider bacterial epidemiology study is needed in order to adjust our local guidelines and the antibiotic therapy. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the local ethic committee of the Robert Debre hospital, Paris, France (number 2021/590bis). Consent for publication Not applicable. Availability of data and materials Not applicable. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions LS, TC, HK: participated in collecting data. LS, AO, TC, HK, BR and CR participated in the design and coordination of the study. LS carried out the statistical analysis and wrote the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Körner H, Söndenaa K, Söreide JA, Andersen E, Nysted A, Lende TH, et al. Incidence of Acute Nonperforated and Perforated Appendicitis: Age-specific and Sex-specific Analysis. World J Surg. 1 mars 1997;21(3):313‑7. Nance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: A continuing diagnostic challenge. Pediatric Emergency Care. juin 2000;16(3):160‑2. Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. The Lancet. 7 mai 2011;377(9777):1573‑9. Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis. JAMA Pediatr. 1 mai 2017;171(5):426‑34. Tanaka Y, Uchida H, Kawashima H, Fujiogi M, Takazawa S, Deie K, et al. Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis. Journal of Pediatric Surgery. 1 nov 2015;50(11):1893‑7. Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 16 juin 2015;313(23):2340‑8. Tiwari MM, Reynoso JF, Tsang AW, Oleynikov D. Comparison of Outcomes of Laparoscopic and Open Appendectomy in Management of Uncomplicated and Complicated Appendicitis. Annals of Surgery. déc 2011;254(6):927‑32. Minneci PC, Hade EM, Lawrence AE, Sebastião YV, Saito JM, Mak GZ, et al. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA. 11 août 2020;324(6):581‑93. Mancini GJ, Mancini ML, Nelson HS. Efficacy of Laparoscopic Appendectomy in Appendicitis with Peritonitis. The American Surgeon. 1 janv 2005;71(1):1‑5. Chang HK, Han SJ, Choi SH, Oh J-T. Feasibility of a Laparoscopic Approach for Generalized Peritonitis from Perforated Appendicitis in Children. Yonsei Med J. 1 nov 2013;54(6):1478‑83. Miyano G, Okazaki T, Kato Y, Marusasa T, Takahashi T, Lane GJ, et al. Open Versus Laparoscopic Treatment for Pan-Peritonitis Secondary to Perforated Appendicitis in Children: A Prospective Analysis. Journal of Laparoendoscopic & Advanced Surgical Techniques. 1 sept 2010;20(7):655‑7. Haller JA, Shaker IJ, Donahoo JS, Schnaufer L, White JJ. Peritoneal drainage versus non-drainage for generalized peritonitis from ruptured appendicitis in children: a prospective study. Ann Surg. mai 1973;177(5):595‑600. Grosfeld JL, Molinari F, Chaet M, Engum SA, West KW, Rescorla FJ, et al. Gastrointestinal perforation and peritonitis in infants and children: Experience with 179 cases over ten years. Surgery. 1 oct 1996;120(4):650‑6. Simillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery. 1 juin 2010;147(6):818‑29. Demetrashvili Z, Kenchadze G, Pipia I, Khutsishvili K, Loladze D, Ekaladze E, et al. Comparison of treatment methods of appendiceal mass and abscess: A prospective Cohort Study. Annals of Medicine and Surgery. 1 déc 2019;48:48‑52. Erdoğan D, Karaman İ, Narcı A, Karaman A, Çavuşoğlu YH, Aslan MK, et al. Comparison of two methods for the management of appendicular mass in children. Ped Surgery Int. 1 févr 2005;21(2):81‑3. Perez KS, Allen SR. Complicated appendicitis and considerations for interval appendectomy. JAAPA. sept 2018;31(9):35‑41. Nimmagadda N, Matsushima K, Piccinini A, Park C, Strumwasser A, Lam L, et al. Complicated appendicitis: Immediate operation or trial of nonoperative management? The American Journal of Surgery. avr 2019;217(4):713‑7. Gillick J, Velayudham M, Puri P. Conservative management of appendix mass in children. British Journal of Surgery. 1 nov 2001;88(11):1539‑42. Taylor E, Dev V, Shah D, Festekjian J, Gaw F. Complicated appendicitis: is there a minimum intravenous antibiotic requirement? A prospective randomized trial. Am Surg. sept 2000;66(9):887‑90. Vaos G, Dimopoulou A, Gkioka E, Zavras N. Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. Journal of Pediatric Surgery. 1 juill 2019;54(7):1365‑71. St. Peter SD, Aguayo P, Fraser JD, Keckler SJ, Sharp SW, Leys CM, et al. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. Journal of Pediatric Surgery. 1 janv 2010;45(1):236‑40. Yau KK, Siu WT, Tang CN, Yang GPC, Li MKW. Laparoscopic Versus Open Appendectomy for Complicated Appendicitis. Journal of the American College of Surgeons. 1 juill 2007;205(1):60‑5. Parmentier B, Berrebi D, Peycelon M, Doit C, Ghoneimi AE, Bonnard A. Failure of First-Line Antibiotics in Nonoperative Management of Appendiceal Mass, toward a Second-Line Instead of Surgery? Eur J Pediatr Surg. juin 2016;26(3):267‑72. Young KA, Neuhaus NM, Fluck M, Blansfield JA, Hunsinger MA, Shabahang MM, et al. Outcomes of complicated appendicitis: Is conservative management as smooth as it seems? The American Journal of Surgery. 1 avr 2018;215(4):586‑92. Mentula P, Sammalkorpi H, Leppäniemi A. Laparoscopic Surgery or Conservative Treatment for Appendiceal Abscess in Adults? A Randomized Controlled Trial. Annals of Surgery. 1 août 2015;262(2):237‑42. Nadler EP, Reblock KK, Vaughan KG, Meza MP, Ford HR, Gaines BA. Predictors of Outcome for Children with Perforated Appendicitis Initially Treated with Non-Operative Management. Surgical Infections. 1 déc 2004;5(4):349‑56. Olsen J, Skovdal J, Qvist N, Bisgaard T. Treatment of appendiceal mass--a qualitative systematic review. Dan Med J. août 2014;61(8):A4881. Aprahamian CJ, Barnhart DC, Bledsoe SE, Vaid Y, Harmon CM. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences. J Pediatr Surg. juin 2007;42(6):934‑8; discussion 938. Talishinskiy T, Limberg J, Ginsburg H, Kuenzler K, Fisher J, Tomita S. Factors associated with failure of nonoperative treatment of complicated appendicitis in children. Journal of Pediatric Surgery. 1 juill 2016;51(7):1174‑6. Tsai H-M, Shan Y-S, Lin P-W, Lin X-Z, Chen C-Y. Clinical analysis of the predictive factors for recurrent appendicitis after initial nonoperative treatment of perforated appendicitis. The American Journal of Surgery. 1 sept 2006;192(3):311‑6. González MC, Rodríguez JCB, Moore EH, Atanay DA. Predictors of recurrent appendicitis after non-operative management of children with perforated appendicitis presenting with an appendicular inflammatory mass. Archives of Disease in Childhood. 1 févr 2014;99(2):154‑7. Shindoh J, Niwa H, Kawai K, Ohata K, Ishihara Y, Takabayashi N, et al. Predictive factors for negative outcomes in initial non-operative management of suspected appendicitis. J Gastrointest Surg. févr 2010;14(2):309‑14. Guillet-Caruba C, Cheikhelard A, Guillet M, Bille E, Descamps P, Yin L, et al. Bacteriologic epidemiology and empirical treatment of pediatric complicated appendicitis. Diagnostic Microbiology and Infectious Disease. 1 avr 2011;69(4):376‑81. Dumont R, Cinotti R, Lejus C, Caillon J, Boutoille D, Roquilly A, et al. The Microbiology of Community-acquired Peritonitis in Children. The Pediatric Infectious Disease Journal. févr 2011;30(2):131‑5. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1975554","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":130641716,"identity":"961ea125-c02d-4f86-b408-d6fb13a0bc79","order_by":0,"name":"Laily Sadozai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYHACAyCWYOBjYGw8wFABZDMzNxCnhY2BseEAwxmQFkaitDAAtTAwHGBsAzEJaJFvP7zx4Y8aCwY29sMNh3nn1UbztwO1/KjYhtuKM2nFBhLHgA7jSQRq2XY8d8ZhxgbGnjO38bgqx0zCgA3kF7CWY7kNQC3MjG24tcj3vzGTSPgH1ML/EKhlzrHc+YS0MNwA2nKwDahFAmRLQ03uBkJaDG48KzZs7JPgYZN42HBwzrEDuRuBWg7i84t8fzIwxL7VyfHzpz988KamLnfe+cMHH/yowOMwKOABEUw8DIfBvAME1cMA4w+GOqIVj4JRMApGwcgBAEsoWleTm9iWAAAAAElFTkSuQmCC","orcid":"","institution":"Robert Ballanger hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Laily","middleName":"","lastName":"Sadozai","suffix":""},{"id":130641718,"identity":"94e3e4a2-94ea-41e8-b8aa-69ac47e25a20","order_by":1,"name":"Taieb Chouikh","email":"","orcid":"","institution":"Robert Ballanger hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Taieb","middleName":"","lastName":"Chouikh","suffix":""},{"id":130641719,"identity":"d300cd0a-6071-4c91-82e6-cfa26c3d74e9","order_by":2,"name":"Henri Kotobi","email":"","orcid":"","institution":"Robert Ballanger hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Henri","middleName":"","lastName":"Kotobi","suffix":""},{"id":130641722,"identity":"825e27df-4e67-4104-82ca-5fc1604743c2","order_by":3,"name":"Benjamin Rossi","email":"","orcid":"","institution":"Robert Ballanger hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Rossi","suffix":""},{"id":130641726,"identity":"ab59ddfc-81a9-459b-a07e-de19b8149bbe","order_by":4,"name":"Bernadette Coret-Houbart","email":"","orcid":"","institution":"Robert Ballanger hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bernadette","middleName":"","lastName":"Coret-Houbart","suffix":""},{"id":130641731,"identity":"c05c072d-24bf-40f8-9514-e053491b1726","order_by":5,"name":"Claire Raquillet","email":"","orcid":"","institution":"Robert Ballanger hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"Raquillet","suffix":""},{"id":130641733,"identity":"af08ed50-907c-4a99-8294-8f09753f4eb3","order_by":6,"name":"Arezki Oufella","email":"","orcid":"","institution":"Robert Ballanger hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Arezki","middleName":"","lastName":"Oufella","suffix":""}],"badges":[],"createdAt":"2022-08-18 15:59:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1975554/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1975554/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":25665596,"identity":"98066ecb-3401-4fd6-b27e-848c1b9d6280","added_by":"auto","created_at":"2022-08-25 16:27:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20860,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart of the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-1975554/v1/ad863103c069e0dce93c7c4b.png"},{"id":25665598,"identity":"0d92e604-8114-4b74-adbc-d5a8ce3ac63b","added_by":"auto","created_at":"2022-08-25 16:27:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21535,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of the CRP rate between the success and the failure groups. \u003c/strong\u003eSeveral biological samples were done during the hospitalization. To analyze the evolution of the CRP rate, we pooled all the CRP rate of the patients in the success group and in the failure group for each biological check-up (samples). Here are the median day corresponding to each samples: S1 (n = 74), day 0 (0-4); S2 (n = 74), day 3 (1-9); S3 (n = 60), day 6 (3-10); S4 (n = 37), day 8 (4-20); S5 (n = 21), day 11 (7-24); S6 (n = 9), day 15 (10-28).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-1975554/v1/c015b0a9f0b6d9b535054294.png"},{"id":25665597,"identity":"bc9a873f-f4e4-4b1c-9af0-1f8a33687f85","added_by":"auto","created_at":"2022-08-25 16:27:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":26499,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of the white blood cell count between the success and the failure groups. \u003c/strong\u003eSeveral biological samples were done during the hospitalization. To analyze the evolution of the white blood cell count, we pooled all the CRP rate of the patients in the success group and in the failure group for each biological check-up (samples). Here are the median day corresponding to each samples: S1 (n = 74), day 0 (0-4); S2 (n = 74), day 3 (1-9); S3 (n = 60), day 6 (3-10); S4 (n = 37), day 8 (4-20); S5 (n = 21), day 11 (7-24); S6 (n = 9), day 15 (10-28).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-1975554/v1/710c232b23cfd9052181e546.png"},{"id":25717015,"identity":"6e6a1b62-866e-462d-b2c1-6bf468b9ebd3","added_by":"auto","created_at":"2022-08-26 16:29:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":478361,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1975554/v1/c7b91a50-f577-4338-b84a-4db860247ed7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Optimization of the medical management of appendicular abscess and plastron in children: a 2009 to 2019 cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003eAppendicitis is an acute inflammation of the appendix and is a common surgical disease of children. It is classified as complicated or uncomplicated depending on the extent of the infection. The incidence of the perforation of the appendix has been reported from 19% to 57% (1,2). In case of isolated appendicitis without any perforation of the appendix: the treatment is based on an emergency appendectomy or in some cases on a conservative treatment with antibiotics (3\u0026ndash;8). In case of a peritonitis due to a perforated appendicitis, the treatment is also based on a surgery with a peritoneal lavage (9\u0026ndash;13). However, the perforation of the appendix can be circumscribed and evolve to an abscess or a plastron. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCurrently, no appropriate guidelines have been made for the management of children with appendicular plastron or abscess especially for the surgical approach, the antibiotic therapy, time to the appendectomy, the diagnostic aspect, etc. Several studies showed that the medical treatment with antibiotics followed by an interval appendectomy was effective and could reduce post-operative complications. Indeed, remote surgical management is optimal to avoid intraoperative complications (small bowel wound, ileo-caecal resection, and stoma) and postoperative complications (flange occlusion, wall abscess) (14\u0026ndash;23).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFailures of the medical treatment of complicated appendicitis is poorly described in the literature and can lead to serious consequences for the patients (24,25). The aim of this study was to attempt to identify predictive factors of success or failure of the initial antibiotic treatment.\u0026nbsp;\u003c/p\u003e"},{"header":"Material and method","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e: We conducted a retrospective single-center study between January 2009 until December 2019 in a primary care center regional hospital. We included all patients under 16 years old, hospitalized in the pediatric surgery unit and diagnosed with appendicular abscess or plastron. \u0026nbsp;The protocol of the pediatric surgery unit of our hospital was based on a conservative treatment for children presenting symptoms for 3 days or more. This conservative treatment included an intravenous broad-spectrum prophylactic antibiotic therapy with: cefotaxime, metronidazole and gentamicin followed by an oral antibiotic therapy (amoxicillin/clavulanic acid) for a total duration of 2 weeks. Finally, an interval appendectomy was scheduled 10 to 12 weeks after the discharge.\u0026nbsp;We defined a failure to the medical treatment as a patient who had at least one of the three criteria. The first one was a failure to the first line of antibiotics (cefotaxime, metronidazole and gentamicine) requiring a switch to a second line (piperacillin/tazobactam and amikacine). Sometimes a third line of antibiotics was considered. This is assessed on a case-by-case basis with the prescription of carbapenem, cefepime or vancomycin, etc.\u0026nbsp;The second criterion was a sudden recurrence of the symptoms occurring between the discharge and the date of the scheduled appendectomy. In the event of a relapse, the patient received a new course of intravenous antibiotics during the hospitalization. The final criterion of failure was an unscheduled emergency appendectomy.\u0026nbsp;All patients performed an ultrasound scan as a first-line protocol and a CT scan if needed.\u0026nbsp;Children with symptoms for less than 3 days had an appendectomy and were excluded from the cohort. We also excluded all the children with generalized peritonitis as well as the children who started the intravenous antibiotic therapy in another hospital center. \u0026nbsp;Ethical approval for this study was obtained from the local ethic committee of the Robert Debre hospital, Paris, France (number 2021/590bis).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design:\u003c/strong\u003e We divided the cohort into a success and a failure group in order to compare different type of data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy variables:\u003c/strong\u003e We collected demographic, drug, clinical, biological, medical imaging and surgical data. Information for patients hospitalized between 2012 and 2019 were collected from electronic medical records while patients hospitalized between 2009 and 2011 had their information in both paper and electronic medical records.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe extracted clinical symptoms at the admission of the patient at the emergency department. Those clinical symptoms were the presence of fever, digestive disorders, vomiting and the presence of a palpable plastron. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBiological markers related to inflammation were collected such as the C-reactive protein (CRP) and white blood cells count. Then, we extracted the bacterial identification in the blood culture and the biological samples.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the medical imaging we analyzed the ultrasound and pelvic abdominal scan records. The following information were collected: whether an ultrasound or a scan were performed, the presence of an abscess or a plastron, the size of the abscess, the presence of a single or multiple abscesses, the presence of a stercolith, the size of the appendix, the presence of an effusion in the right iliac fossa or in the pouch of Douglas.\u003c/p\u003e\n\u003cp\u003eDrug data analyzed were drug taken before the hospitalization, the antibiotic therapy prescribed, the dose, the frequency of administration, the route of administration, the duration of the antibiotic therapy, the delay from the beginning of the hospitalization and the prescription as a first, second- or third-line treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis:\u003c/strong\u003e Statistical tests were carried out using SAS\u0026reg; software (version 9.4). Categorical variables are expressed as N (%) and quantitative variables are expressed as median (min-max). The data for the success versus failure group were compared using the Chi2 test for categorical variables with numbers greater than 5 and a Fisher test for the opposite case. For the comparison of quantitative variables within the two groups, a Mann-Whitney test was performed. Values were considered significant when the p-value was less than 0.05.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic data:\u0026nbsp;\u003c/strong\u003eBetween 2009 and 2019, 74 patients were diagnosed with an appendicular abscess or plastron and were treated with intravenous antibiotics (see \u003cstrong\u003efigure 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe number of patients diagnosed with appendicular abscess treated with intravenous antibiotics varied each year with a minimum of 1 and up to 11 (see \u003cstrong\u003etable\u0026nbsp;1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 1:\u003c/strong\u003e\u003cstrong\u003eEvolution of the number of successes and failures to the medical treatment from 2009 to 2019\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.227963525835865%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2009\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2010\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2011\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2012\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2013\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2014\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2015\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2016\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2018\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"28.875379939209726%\"\u003e\n \u003cp\u003e1 (100 %)\u003c/p\u003e\n \u003cp\u003e4 (80%)\u003c/p\u003e\n \u003cp\u003e7 (64%)\u003c/p\u003e\n \u003cp\u003e2 (67%)\u003c/p\u003e\n \u003cp\u003e6 (67%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e5 (100%)\u003c/p\u003e\n \u003cp\u003e4 (50%)\u003c/p\u003e\n \u003cp\u003e6 (55%)\u003c/p\u003e\n \u003cp\u003e6 (60%)\u003c/p\u003e\n \u003cp\u003e6 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.835866261398177%\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003cp\u003e4 (36%)\u003c/p\u003e\n \u003cp\u003e1 (33%)\u003c/p\u003e\n \u003cp\u003e3 (33%)\u003c/p\u003e\n \u003cp\u003e3 (100%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e4 (50%)\u003c/p\u003e\n \u003cp\u003e5 (45%)\u003c/p\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003cp\u003e2 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"20.060790273556233%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePatients included in the success group (n = 47, 64%) and the failure group (n = 27, 36%) were respectively aged 8.7 years old (2-14) and 9.4 years old (2-15) (p = 0.43) (see \u003cstrong\u003etable\u0026nbsp;2\u003c/strong\u003e). Length of hospitalization stay was significantly different between the two groups: 8 (5-12) in the success group compared to 15 days (6-29) in the failure group (p \u0026lt; 0.0001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Table 2:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDemographic, clinical and imaging description of the patients included in the study\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003e\u0026nbsp;Data expressed in n (%) or median (min-max)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003eSuccesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eFailures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e47 (64 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e27 (36 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e26 (55 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e13 (48 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e21 (45 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e14 (52 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eAge (years old)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e8,7 (2-14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e9,4 (2-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e30,9 (12,5-69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e30,6 (11-68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eDuration of symptoms before admission (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e5 (2-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e4,85 (3-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eAntibiotic(s) before admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e6 (13 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e7 (26 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eNSAI before admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e2 (4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e2 (7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eLenght of hospitalization stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e7,9 (5-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e14,9 (6-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0,0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eTotal duration of antibiotherapy (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e13,2 (5-21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e18,8 (7-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical signs at the admission\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e27 (57 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e18 (67 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eDiarrhea/liquid stools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e9 (19 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e12 (44 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003ePalpable mass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e22 (47 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e18 (67 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e36 (77 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e21 (78 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eIntestinal occlusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e3 (6,4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e3 (11 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical imaging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003ePlastron\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e16 (34 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e5 (19 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eAbscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e31 (66 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e22 (81 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;- Simple abscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e29 (93,5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e15 (68 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;- Multiple abscesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e2 (6,5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e7 (32 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.816046966731896%\"\u003e\n \u003cp\u003eStercolith\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.59099804305284%\"\u003e\n \u003cp\u003e16 (34 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003e14 (52 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.154598825831702%\"\u003e\n \u003cp\u003e0,13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eOther medications received before admission:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our cohort, 6 (13%) patients of the success group were treated with antibiotics before the admission with amoxicillin (n = 2), amoxicillin/clavulanic acid (n = 1), cefixime (n\u0026nbsp;= 1) or cefpodoxime (n = 1). Two patients (4%) also received non-steroidal anti-inflammatory drug.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIn the failure group, 7 (26%) patients were also treated with antibiotics such as: amoxicillin (n = 4), cefpodoxime (n = 1) or ceftriaxone (n = 1, for a suspected acute gastroenteritis with \u003cem\u003eSalmonella spp\u003c/em\u003e.)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical symptoms:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong all the clinical signs, a significant difference was found in the number of children with diarrhea and loose stools in the failure group at admission (p\u0026nbsp;=\u0026nbsp;0.02). A trend towards a predominance of palpable mass was also observed in this group (n\u003csub\u003esuccess\u0026nbsp;\u003c/sub\u003e= 22 (47%) and n\u003csub\u003efailure\u0026nbsp;\u003c/sub\u003e= 18 (67%), p = 0.09). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical imaging:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 53 patients with abscess, 44 (83%) had a single abscess and 9 (17%) were multiple. Multiple abscesses were more likely to escape the medical treatment (7/9, 78%) compared to single abscesses (15/44, 34%) (p=0.02). Finally, 30 (40.5%) of the patients had stercoliths: 14 (52%) in the failure group and 16 (34%) in the success group. However, this trend was not statistically significant between the two groups (p = 0.13). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBiological values:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the admission, the CRP level was slightly higher in the failure group (157.4 mg/L [55-341]) than in the success group (131.7 mg/L [9-386]) (p = 0.22) (see \u003cstrong\u003efigure 2\u003c/strong\u003e). On the second biological check-up (S2) - i.e., at day 3 [1-9] - it was not possible to dissociate one group from the other (n\u003csub\u003esuccess\u003c/sub\u003e = 99.4 mg/L, n\u003csub\u003efailure\u003c/sub\u003e = 94.8 mg/L, p = 0.43). The 3\u003csup\u003erd\u003c/sup\u003e biological check-up - i.e. at day 6 [3-10] \u0026ndash; was the tipping point to distinguish whether the medical management was effective or not because the CRP rate fell by an average of 33% in the success group while it was stable or increasing in the failure group (p = 0.0038).\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003efigure 3\u003c/strong\u003e representing the white blood cell count showed that the values for the first and second biological check-up were not significantly different between the two groups. There was a clear difference between the two group at the third biological check-up (S3) - i.e. at day 6 [3-10] - with a decrease of the values in the success group (10.9 G/L [3.6-21.3]) and an increase in the failure group (15.1 G/L [5.3-28.5]) (p = 0.0018).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, only 17 (23%) patients had a documented infection with bacteria growing in their biological samples. The main bacteria found were strict anaerobic bacteria, \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eStreptococcus spp\u003c/em\u003e.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe management of children with appendicular abscess remains controversial as there is no consensus regarding the guidelines. Several studies proved that conservative treatment with antibiotics could ease and optimize a delayed surgery. The meta-analysis by Similis et al. included 17 randomized and non-randomized studies comparing immediate surgery with conservative treatment (14). The complications were significantly higher after an immediate appendectomy: bowel obstruction, deep abdominal or pelvic abscesses and wound infections. This result was then confirmed by the recent meta-analysis by Vaos et al. and by other studies (15,16,18,21,26).\u003c/p\u003e\n\n\u003cp\u003eThe medical management was interesting by reducing post-operative complications (14). Still, the success of this medical protocol was not entirely guaranteed. Depending on the study, the success rate varied between 74 and 92% (24,27,28). The success rate of our study was lower with 64% of our cohort. The definition of non-response to the medical treatment was quite different from one study to another. Indeed, in our study, the failure criteria were broader as we included all patients for whom the first line of treatment was not effective enough and who therefore required a change in the antibiotic therapy (which is not the cause of most of the similar studies), re-hospitalization or an unscheduled surgery. \u003c/p\u003e\n\n\u003cp\u003eThe failure of the treatment could lead to serious consequences: prolonged hospitalization, parental anxiety and sometimes treatment impasses. For example, one patient of our cohort received a total course of 21 days of intravenous antibiotics with cefotaxime, metronidazole and gentamicin until day 7, piperacillin/tazobactam and amikacin until day 14 and finally ceftazidime, metronidazole and vancomycin until day 21. At the end, the patient was still not responding to the antibiotics with growing abscesses and clinical deterioration. In our hospital, this patient was not eligible for a surgery as it is not recommended after one week of hospitalization because of the adherences and the strong risks of surgery complications. This highlight the importance of early identification of patients who may not respond to the medical treatment and who may benefit from a surgery during the first week of hospitalization. \u003c/p\u003e\n\n\u003cp\u003eEarly identification of those patients is a real challenge. Some predictive factors were analyzed in previous studies as well as in our study (27,29,29,30). First of all, the two groups of our cohort showed no major differences of the CRP and the white blood cell levels at admission. We paid particular attention to the dynamics of the CRP and the with blood cells, all along the hospitalization. We observed that one week was needed to differentiate a patient who is not responding to the medical treatment with a stabilization or an increase of the inflammatory markers. This highlight the fact that it is crucial to find other early predictive factors in order to adjust the treatment sooner, during the first week of hospitalization. Children with multiple abscesses and diarrhea had statistically more failures than others. This is the first study to conclude with an exclusion of the children with multiple abscesses from the conservative treatment. Then, the presence of stercoliths was not significantly associated with failure, even though there was a trend. This contradict the results of other studies, probably due to the number of patients included or the study design (29,31\u0026ndash;33). Indeed, in retrospective studies, it is not impossible that the presence or absence of stercoliths was not systematically specified by the radiologists when writing the report, making the analysis less reliable. However, we can recommend greater vigilance in the follow-up after detecting stercoliths in the medical imaging. We also observed more frequent palpable masses during the clinical examination of patients for whom the first line treatment was not effective \u0026ndash; probably because of the size of the collection. Finally, time to apyrexia and time to hospitalization did not influence the complexity of the patient\u0026rsquo;s management in our cohort. It seemed that these two criteria, although logical, did not allow us to identify groups at risk of failure. \u003c/p\u003e\n\n\u003cp\u003eThe main limitation of our study was the retrospective nature which may lead to bias, but also the small number of patients included. Thus, the lack of power due to the small number of data did not allow us to show any significant differences for some criteria between the two groups although some trends was observed. \u003c/p\u003e\n\n\u003cp\u003eIndeed, for example, the bacteria causing appendicular abscess were rarely documented but the main germs found in the few samples of our cohort were strict anaerobic bacteria, \u003cem\u003eEscherichia coli\u003c/em\u003e or \u003cem\u003eStreptococcus spp\u003c/em\u003e. This results were similar to other studies (34,35). However, these results cannot be interpreted as the drainage was done after the initiation of the antibiotic therapy and because of the small number of documented infections. The choice of the antibiotic therapy should be assessed as it could be one of many reasons leading to the failure. The hypothesis raised here is that the first line of the antibiotic therapy may not cover the majority of the bacteria causing pediatric digestive infections in our sector. In the future, a wider bacterial epidemiology study is needed to complete our results and to fully adjust our local guidelines and the antibiotic therapy for children with appendicular abscess or plastron. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe management of children with appendicular abscess and plastron remains controversial and is different from one hospital to another. Many studies proved the benefits of the medical treatment although a significant rate of failures has been observed in our hospital from 2009 until 2019. Several factors were analyzed to predict the response to the medical treatment. Patients with multiple abscesses will no longer be treated with antibiotics. We also recommended greater vigilance after detecting stercoliths in the medical imaging based on other studies results. Time to hospitalization, time to apyrexia, CRP and white blood cells level at admission were not different between the success and the failure group. Finally, a wider bacterial epidemiology study is needed in order to adjust our local guidelines and the antibiotic therapy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the local ethic committee of the Robert Debre hospital, Paris, France (number 2021/590bis).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLS, TC, HK: participated in collecting data. LS, AO, TC, HK, BR and CR participated in the design and coordination of the study. LS carried out the statistical analysis and wrote the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eK\u0026ouml;rner H, S\u0026ouml;ndenaa K, S\u0026ouml;reide JA, Andersen E, Nysted A, Lende TH, et al. Incidence of Acute Nonperforated and Perforated Appendicitis: Age-specific and Sex-specific Analysis. World J Surg. 1 mars 1997;21(3):313‑7. \u003c/li\u003e\n\u003cli\u003eNance ML, Adamson WT, Hedrick HL. Appendicitis in the young child: A continuing diagnostic challenge. Pediatric Emergency Care. juin 2000;16(3):160‑2. \u003c/li\u003e\n\u003cli\u003eVons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. The Lancet. 7 mai 2011;377(9777):1573‑9. \u003c/li\u003e\n\u003cli\u003eHuang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis. JAMA Pediatr. 1 mai 2017;171(5):426‑34. \u003c/li\u003e\n\u003cli\u003eTanaka Y, Uchida H, Kawashima H, Fujiogi M, Takazawa S, Deie K, et al. Long-term outcomes of operative versus nonoperative treatment for uncomplicated appendicitis. Journal of Pediatric Surgery. 1 nov 2015;50(11):1893‑7. \u003c/li\u003e\n\u003cli\u003eSalminen P, Paajanen H, Rautio T, Nordstr\u0026ouml;m P, Aarnio M, Rantanen T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 16 juin 2015;313(23):2340‑8. \u003c/li\u003e\n\u003cli\u003eTiwari MM, Reynoso JF, Tsang AW, Oleynikov D. Comparison of Outcomes of Laparoscopic and Open Appendectomy in Management of Uncomplicated and Complicated Appendicitis. Annals of Surgery. d\u0026eacute;c 2011;254(6):927‑32. \u003c/li\u003e\n\u003cli\u003eMinneci PC, Hade EM, Lawrence AE, Sebasti\u0026atilde;o YV, Saito JM, Mak GZ, et al. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA. 11 ao\u0026ucirc;t 2020;324(6):581‑93. \u003c/li\u003e\n\u003cli\u003eMancini GJ, Mancini ML, Nelson HS. Efficacy of Laparoscopic Appendectomy in Appendicitis with Peritonitis. The American Surgeon. 1 janv 2005;71(1):1‑5. \u003c/li\u003e\n\u003cli\u003eChang HK, Han SJ, Choi SH, Oh J-T. Feasibility of a Laparoscopic Approach for Generalized Peritonitis from Perforated Appendicitis in Children. Yonsei Med J. 1 nov 2013;54(6):1478‑83. \u003c/li\u003e\n\u003cli\u003eMiyano G, Okazaki T, Kato Y, Marusasa T, Takahashi T, Lane GJ, et al. Open Versus Laparoscopic Treatment for Pan-Peritonitis Secondary to Perforated Appendicitis in Children: A Prospective Analysis. Journal of Laparoendoscopic \u0026amp; Advanced Surgical Techniques. 1 sept 2010;20(7):655‑7. \u003c/li\u003e\n\u003cli\u003eHaller JA, Shaker IJ, Donahoo JS, Schnaufer L, White JJ. Peritoneal drainage versus non-drainage for generalized peritonitis from ruptured appendicitis in children: a prospective study. Ann Surg. mai 1973;177(5):595‑600. \u003c/li\u003e\n\u003cli\u003eGrosfeld JL, Molinari F, Chaet M, Engum SA, West KW, Rescorla FJ, et al. Gastrointestinal perforation and peritonitis in infants and children: Experience with 179 cases over ten years. Surgery. 1 oct 1996;120(4):650‑6. \u003c/li\u003e\n\u003cli\u003eSimillis C, Symeonides P, Shorthouse AJ, Tekkis PP. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery. 1 juin 2010;147(6):818‑29. \u003c/li\u003e\n\u003cli\u003eDemetrashvili Z, Kenchadze G, Pipia I, Khutsishvili K, Loladze D, Ekaladze E, et al. Comparison of treatment methods of appendiceal mass and abscess: A prospective Cohort Study. Annals of Medicine and Surgery. 1 d\u0026eacute;c 2019;48:48‑52. \u003c/li\u003e\n\u003cli\u003eErdoğan D, Karaman İ, Narcı A, Karaman A, \u0026Ccedil;avuşoğlu YH, Aslan MK, et al. Comparison of two methods for the management of appendicular mass in children. Ped Surgery Int. 1 f\u0026eacute;vr 2005;21(2):81‑3. \u003c/li\u003e\n\u003cli\u003ePerez KS, Allen SR. Complicated appendicitis and considerations for interval appendectomy. JAAPA. sept 2018;31(9):35‑41. \u003c/li\u003e\n\u003cli\u003eNimmagadda N, Matsushima K, Piccinini A, Park C, Strumwasser A, Lam L, et al. Complicated appendicitis: Immediate operation or trial of nonoperative management? The American Journal of Surgery. avr 2019;217(4):713‑7. \u003c/li\u003e\n\u003cli\u003eGillick J, Velayudham M, Puri P. Conservative management of appendix mass in children. British Journal of Surgery. 1 nov 2001;88(11):1539‑42. \u003c/li\u003e\n\u003cli\u003eTaylor E, Dev V, Shah D, Festekjian J, Gaw F. Complicated appendicitis: is there a minimum intravenous antibiotic requirement? A prospective randomized trial. Am Surg. sept 2000;66(9):887‑90. \u003c/li\u003e\n\u003cli\u003eVaos G, Dimopoulou A, Gkioka E, Zavras N. Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. Journal of Pediatric Surgery. 1 juill 2019;54(7):1365‑71. \u003c/li\u003e\n\u003cli\u003eSt. Peter SD, Aguayo P, Fraser JD, Keckler SJ, Sharp SW, Leys CM, et al. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. Journal of Pediatric Surgery. 1 janv 2010;45(1):236‑40. \u003c/li\u003e\n\u003cli\u003eYau KK, Siu WT, Tang CN, Yang GPC, Li MKW. Laparoscopic Versus Open Appendectomy for Complicated Appendicitis. Journal of the American College of Surgeons. 1 juill 2007;205(1):60‑5. \u003c/li\u003e\n\u003cli\u003eParmentier B, Berrebi D, Peycelon M, Doit C, Ghoneimi AE, Bonnard A. Failure of First-Line Antibiotics in Nonoperative Management of Appendiceal Mass, toward a Second-Line Instead of Surgery? Eur J Pediatr Surg. juin 2016;26(3):267‑72. \u003c/li\u003e\n\u003cli\u003eYoung KA, Neuhaus NM, Fluck M, Blansfield JA, Hunsinger MA, Shabahang MM, et al. Outcomes of complicated appendicitis: Is conservative management as smooth as it seems? The American Journal of Surgery. 1 avr 2018;215(4):586‑92. \u003c/li\u003e\n\u003cli\u003eMentula P, Sammalkorpi H, Lepp\u0026auml;niemi A. Laparoscopic Surgery or Conservative Treatment for Appendiceal Abscess in Adults? A Randomized Controlled Trial. Annals of Surgery. 1 ao\u0026ucirc;t 2015;262(2):237‑42. \u003c/li\u003e\n\u003cli\u003eNadler EP, Reblock KK, Vaughan KG, Meza MP, Ford HR, Gaines BA. Predictors of Outcome for Children with Perforated Appendicitis Initially Treated with Non-Operative Management. Surgical Infections. 1 d\u0026eacute;c 2004;5(4):349‑56. \u003c/li\u003e\n\u003cli\u003eOlsen J, Skovdal J, Qvist N, Bisgaard T. Treatment of appendiceal mass--a qualitative systematic review. Dan Med J. ao\u0026ucirc;t 2014;61(8):A4881. \u003c/li\u003e\n\u003cli\u003eAprahamian CJ, Barnhart DC, Bledsoe SE, Vaid Y, Harmon CM. Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences. J Pediatr Surg. juin 2007;42(6):934‑8; discussion 938. \u003c/li\u003e\n\u003cli\u003eTalishinskiy T, Limberg J, Ginsburg H, Kuenzler K, Fisher J, Tomita S. Factors associated with failure of nonoperative treatment of complicated appendicitis in children. Journal of Pediatric Surgery. 1 juill 2016;51(7):1174‑6. \u003c/li\u003e\n\u003cli\u003eTsai H-M, Shan Y-S, Lin P-W, Lin X-Z, Chen C-Y. Clinical analysis of the predictive factors for recurrent appendicitis after initial nonoperative treatment of perforated appendicitis. The American Journal of Surgery. 1 sept 2006;192(3):311‑6. \u003c/li\u003e\n\u003cli\u003eGonz\u0026aacute;lez MC, Rodr\u0026iacute;guez JCB, Moore EH, Atanay DA. Predictors of recurrent appendicitis after non-operative management of children with perforated appendicitis presenting with an appendicular inflammatory mass. Archives of Disease in Childhood. 1 f\u0026eacute;vr 2014;99(2):154‑7. \u003c/li\u003e\n\u003cli\u003eShindoh J, Niwa H, Kawai K, Ohata K, Ishihara Y, Takabayashi N, et al. Predictive factors for negative outcomes in initial non-operative management of suspected appendicitis. J Gastrointest Surg. f\u0026eacute;vr 2010;14(2):309‑14. \u003c/li\u003e\n\u003cli\u003eGuillet-Caruba C, Cheikhelard A, Guillet M, Bille E, Descamps P, Yin L, et al. Bacteriologic epidemiology and empirical treatment of pediatric complicated appendicitis. Diagnostic Microbiology and Infectious Disease. 1 avr 2011;69(4):376‑81. \u003c/li\u003e\n\u003cli\u003eDumont R, Cinotti R, Lejus C, Caillon J, Boutoille D, Roquilly A, et al. The Microbiology of Community-acquired Peritonitis in Children. The Pediatric Infectious Disease Journal. f\u0026eacute;vr 2011;30(2):131‑5. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"perforated appendicitis, abscess, antibiotic, children","lastPublishedDoi":"10.21203/rs.3.rs-1975554/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1975554/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIn our hospital, children with appendicular plastron or abscess receive a medical treatment with cefotaxime, metronidazole and gentamicin followed by amoxicillin/clavulanic acid as an oral switch. Appendectomy is performed 10 to 12 weeks after the beginning of the discharge. A high failure rate was noticed with a switch to a second line treatments, rehospitalization or an emergency surgery. The objective of our study was to highlight predictive factors for the treatment response. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We conducted a retrospective monocentric study between 2009 and 2019. Inclusion criteria were children under 16 years old diagnosed with appendicular plastron or abscess, treated with a medical treatment. We divided the cohort into a success and a failure group and compared their demographic data, clinical symptoms, inflammatory markers, abdominal imaging and antibiotic regimen. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Seventy-four patients were enrolled in the study and the failure rate was 36% (n=27). The median age in the success group was 8.7 years old (2-14) and 9.4 years old (2-15) in the failure group. Multiple abscesses (6.5% \u003cem\u003eversus\u003c/em\u003e 32%, p=0.02) and diarrhea at admission (19% \u003cem\u003eversus \u003c/em\u003e44%, p=0.02) were significantly associated with a failure. Palpable mass (47% \u003cem\u003eversus\u003c/em\u003e 67%, p=0.09) and stercoliths (34% \u003cem\u003eversus\u003c/em\u003e 52%, p=0.13) appeared to be more important in the failure group. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDiscussion and conclusion:\u003c/strong\u003e Several factors were analyzed to predict the response to the medical treatment for children with appendicular abscess or plastron. Patients with multiple abscesses will no longer be treated with antibiotics. We also recommended greater vigilance after detecting stercoliths in the medical imaging based on other studies results. Time to hospitalization, time to apyrexia, CRP and white blood cells level at admission were not different between the success and the failure group. Finally, a wider bacterial epidemiology study is needed in order to adjust our local guidelines and the antibiotic therapy.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Optimization of the medical management of appendicular abscess and plastron in children: a 2009 to 2019 cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-25 16:26:59","doi":"10.21203/rs.3.rs-1975554/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72cb7af3-46c6-476e-b044-7298db2cc97f","owner":[],"postedDate":"August 25th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-10-18T08:14:30+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-25 16:26:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1975554","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1975554","identity":"rs-1975554","version":["v1"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}