Bacterial Culture and Antimicrobial Susceptibility Analysis of Purulent Specimens in Pediatric Acute Appendicitis
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Bacterial Culture and Antimicrobial Susceptibility Analysis of Purulent Specimens in Pediatric Acute Appendicitis | 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 Article Bacterial Culture and Antimicrobial Susceptibility Analysis of Purulent Specimens in Pediatric Acute Appendicitis Yan Peng, Mengqi Li, Huaiwei Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9428869/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 To characterize microbial distribution and antimicrobial susceptibility profiles in purulent specimens from pediatric acute appendicitis, guiding evidence-based antibiotic therapy optimization. In this prospective cohort study, intraoperative pus samples were collected from 70 consecutive pediatric patients undergoing appendectomy between January 2024 and January 2025. Bacterial identification was performed using the VITEK 2 Compact system. Antimicrobial susceptibility testing was conducted via broth microdilution for minimum inhibitory concentration (MIC) determination. Extended-spectrum β-lactamase (ESBL) production was confirmed using the Clinical and Laboratory Standards Institute (CLSI) double-disk synergy test. Pathogens were isolated from 88.6% of specimens (62/70), with Gram-negative bacteria predominating (98.3%, 61/62). The most common isolates were Escherichia coli (74.2%, 46/62) and Pseudomonas aeruginosa (14.5%, 9/62). E. coli exhibited high susceptibility to amikacin (93.5%), imipenem (97.8%), and tigecycline (100%), but elevated resistance to co-trimoxazole (82.6%) and ceftriaxone (78.3%). All P. aeruginosa isolates were susceptible to the tested antimicrobial agents. ESBL production was detected in 41.3% (19/46) of E. coli isolates. Gram-negative pathogens, particularly E. coli and P. aeruginosa , are the primary etiological agents in pediatric acute appendicitis. Empirical antibiotic therapy should prioritize agents effective against ESBL-producing strains, with carbapenems or aminoglycosides recommended as first-line options pending local susceptibility data. Health sciences/Diseases Health sciences/Medical research Biological sciences/Microbiology Microbial distribution Antimicrobial susceptibility Antibiotic resistance Empirical antibiotic therapy 1. Introduction Acute appendicitis is among the most common surgical emergencies in the pediatric population. It typically presents with periumbilical pain that migrates to the right lower quadrant, accompanied by nausea, vomiting, diarrhea, and fever [ 1 ] . In recent years, the incidence of pediatric acute appendicitis has risen, potentially due to changes in lifestyle and dietary habits [ 2 – 3 ] . The anatomical and physiological characteristics of children often lead to rapid disease progression and severe complications such as perforation and peritonitis. Thus, prompt diagnosis and appropriate intervention are critical for improving outcomes. Current management primarily involves appendectomy combined with antimicrobial therapy to control infection and facilitate recovery [ 4 ] . However, selecting optimal antimicrobial regimens remains challenging. Variations in regional bacterial epidemiology and resistance patterns often lead to inconsistent efficacy with empirical antibiotic use, which may contribute to treatment failure, increased healthcare costs, and antimicrobial resistance [ 5 ] . Therefore, understanding local microbiological profiles and susceptibility patterns is essential for rational antibiotic selection. This study aims to investigate the bacterial distribution and antimicrobial resistance patterns in purulent specimens from pediatric acute appendicitis cases through microbiological culture and susceptibility testing. The results are intended to support evidence-based antibiotic selection, improve therapeutic efficacy, reduce inappropriate antibiotic use, and decrease complication rates. Furthermore, this work provides a foundation for future research aimed at enhancing diagnostic and treatment strategies for pediatric acute appendicitis. 2. Materials and Methods 2.1 Study Population and Specimen Collection Seventy pediatric patients (48 males, 22 females; age range 3–12 years, mean 7.5 years) diagnosed with acute appendicitis were consecutively enrolled between January 2024 and January 2025 at Fuyang Maternity and Child Health Care Hospital. All patients met the diagnostic criteria for acute appendicitis and developed postoperative incision infections as defined by the Hospital-Acquired Infection Diagnostic Standards (Trial Version) [ 6 ] . Patients with a history of abdominal surgery or concurrent infections at admission were excluded. The study was approved by the institutional ethics committee, and written informed consent was obtained from legal guardians. All methods were performed in accordance with the relevant guidelines and regulations (e.g., the Declaration of Helsinki). 2.2 Instruments and Reagents Microbiological analyses were performed using the VITEK® 2 Compact automated system (bioMérieux, France) with GP/GN identification cards and GP67/GN13 susceptibility test cards. Blood agar, MacConkey agar, and chocolate agar plates were supplied by Hefei Tianda Diagnostic Reagents Co., Ltd. Quality control strains (Escherichia coli ATCC® 25922 and Pseudomonas aeruginosa ATCC® 27853) were obtained from the National Center for Clinical Laboratories. All reagents were used within their expiration dates. 2.3 Experimental Procedures 2.3.1 Specimen Collection and Processing Pus samples were aseptically collected using sterile swabs during appendectomy. Specimens were transported in sterile containers to the clinical microbiology laboratory within 60 minutes. They were inoculated onto blood and MacConkey agar plates using a quadrant streak method and incubated at 35°C for 18–24 hours. 2.3.2 Bacterial Identification Single colonies were purified and subjected to Gram staining. Gram-positive and Gram-negative isolates were identified using GP and GN cards, respectively, on the VITEK® 2 Compact system following standard clinical microbiology protocols. 2.3.3 Antimicrobial Susceptibility Testing Minimum inhibitory concentrations (MICs) were determined using broth microdilution method. Extended-spectrum β-lactamase (ESBL) production was confirmed through double-disk synergy testing. All procedures and interpretive criteria complied with current Clinical and Laboratory Standards Institute (CLSI) guidelines. 2.3.4 Statistical Analysis Data were analyzed using SPSS version 25.0 (IBM Corp.). Categorical variables are expressed as frequencies, and continuous variables as mean ± standard deviation. 3. Results 3.1 Distribution of Appendicitis Subtypes Among the 70 cases, pathological subtypes included: acute appendicitis with peritonitis (67.1%, n = 47), acute simple appendicitis (12.9%, n = 9), acute suppurative appendicitis with diffuse peritonitis (7.1%, n = 5), acute appendicitis with perforation (5.7%, n = 4), acute appendicitis perforation with diffuse peritonitis (5.7%, n = 4), and acute gangrenous appendicitis with perforation (1.4%, n = 1) (Table 1 ). Table 1 Pathological subtypes of acute appendicitis (n = 70) Type of Appendicitis Number of Cases Percentage (%) Acute appendicitis with peritonitis 47 67.1 Acute simple appendicitis 9 12.9 Acute suppurative appendicitis with diffuse peritonitis 5 7.1 Acute appendicitis with perforation 4 5.7 Acute appendicitis with perforation and diffuse peritonitis 4 5.7 Acute gangrenous appendicitis with perforation 1 1.4 3.2 Pathogen Distribution Microbiological analysis identified 62 pathogenic isolates from 70 specimens, yielding a positive detection rate of 88.6%. Gram-positive bacteria accounted for 1.6% (1 isolate: Enterococcus avium ), while Gram-negative organisms predominated at 98.3% (61 isolates). The latter comprised Escherichia coli (74.2%, 46 isolates), Pseudomonas aeruginosa (14.5%, 9 isolates), Proteus mirabilis (3.2%, 2 isolates), Comamonas testosteroni (4.8%, 3 isolates), and Klebsiella pneumoniae (1.6%, 1 isolate) (Table 2 ). Table 2 Pathogenic bacteria isolated from purulent specimens (n = 62) Pathogen Number of Strains Percentage (%) Escherichia coli 46 74.2 Pseudomonas aeruginosa 9 14.5 Comamonas testosteroni 3 4.8 Proteus mirabilis 2 3.2 Klebsiella pneumoniae 1 1.6 Enterococcus avium 1 1.6 3.3 Antimicrobial Susceptibility of Predominant Pathogens Antibiotic susceptibility testing revealed distinct resistance patterns in Escherichia coli (n = 46) and Pseudomonas aeruginosa (n = 9). E. coli demonstrated very high susceptibility to amikacin, imipenem, tigecycline, ertapenem, cefoperazone, and piperacillin, with resistance rates ranging from 0% to 4.3%. Conversely, elevated resistance (> 40%) was observed against trimethoprim-sulfamethoxazole, cefuroxime sodium, ceftriaxone, cefuroxime axetil, and levofloxacin. P. aeruginosa exhibited 100% susceptibility to amikacin, imipenem, cefepime, ceftazidime, cefoperazone, levofloxacin, piperacillin, tobramycin, meropenem, and ciprofloxacin (resistance rate 0%). However, intermediate susceptibility was observed for ticarcillin (2 isolates) and colistin (1 isolate). The absence of resistant P. aeruginosa strains in this cohort may be attributed to the limited sample size (Tables 3 and 4 ). Table 3 Antimicrobial susceptibility of Escherichia coli (n = 46) Antibiotic S R I Resistance rate (%) Amikacin 45 0 1 0 Imipenem 46 0 0 0 Cefoxitin 37 6 3 13 Cefepime 31 15 0 32.6 Trimethoprim-sulfamethoxazole 14 32 0 69.6 Tigecycline 45 1 0 2.2 Amoxicillin 31 7 8 15.2 Ceftazidime 27 13 6 28.3 Ertapenem 46 0 0 0 Cefuroxime sodium 21 22 3 47.8 Ceftriaxone 24 22 0 47.8 Cefoperazone 45 0 1 0 Levofloxacin 9 19 18 41.3 Piperacillin 44 2 0 4.3 Cefuroxime axetil 25 22 3 47.8 Note: S = Susceptible, R = Resistant, I = Intermediate Table 4 Antimicrobial susceptibility of Pseudomonas aeruginosa (n = 9) Antibiotic S R I Resistance rate (%) Amikacin 9 0 0 0 Imipenem 9 0 0 0 Cefepime 9 0 0 0 Ceftazidime 9 0 0 0 Cefoperazone 9 0 0 0 Levofloxacin 9 0 0 0 Piperacillin 9 0 0 0 Colistin 8 0 1 0 Ticarcillin 7 0 2 0 Tobramycin 9 0 0 0 Meropenem 9 0 0 0 Ciprofloxacin 9 0 0 0 Note: S = Susceptible, R = Resistant, I = Intermediate 3.4 Extended-Spectrum β-Lactamase (ESBL) Production Among Escherichia coli Isolates Among the 46 Escherichia coli isolates, ESBL-producing strains were identified in 19 cases (41.3%), with the remaining 27 isolates (58.7%) classified as non-ESBL-producing (Table 5 ). Table 5 ESBL production in Escherichia coli isolates (n = 46) ESBL production Strains Percentage (%) ESBL-producing 19 41.3 Non-ESBL-producing 27 58.7 4. Discussion Acute appendicitis, one of the most common surgical emergencies in general surgery, typically manifests with periumbilical or epigastric pain that migrates and localizes to McBurney's point in the right lower quadrant, accompanied by fixed tenderness on palpation. Although its incidence in pediatric populations is lower than in adults, the condition often progresses more rapidly with higher risks of complications such as perforation and diffuse peritonitis, necessitating heightened clinical vigilance [ 7 ] . This study systematically analyzed bacterial culture and antimicrobial susceptibility profiles of purulent secretions from 70 pediatric acute appendicitis cases, elucidating pathogen distribution patterns and resistance characteristics to inform evidence-based antibiotic selection. Among the 70 specimens, 62 pathogenic isolates were identified (detection rate: 88.6%). Gram-negative bacteria predominated (98.3%), with Escherichia coli (74.2%) and Pseudomonas aeruginosa (14.5%) constituting the primary pathogens. These findings align with studies by You et al. [ 7 – 8 ] , confirming Gram-negative bacteria, particularly E. coli , as predominant etiological agents in pediatric acute appendicitis. Gram-positive bacteria were rare (1.6%, Enterococcus avium ). Antimicrobial susceptibility testing revealed substantial resistance heterogeneity: E. coli exhibited high resistance (> 40%) to cefuroxime sodium, ceftriaxone, cefuroxime axetil, and levofloxacin while demonstrating marked susceptibility (> 70%) to amikacin, imipenem, tigecycline, ertapenem, cefoperazone, and piperacillin. Conversely, P. aeruginosa showed 100% susceptibility to amikacin, imipenem, cefepime, ceftazidime, cefoperazone, levofloxacin, piperacillin, tobramycin, meropenem, and ciprofloxacin, consistent with findings by Zhuang et al. and Ye et al. [ 9 – 10 ] . These results suggest prioritizing ceftazidime or amoxicillin for E. coli infections, and piperacillin or tobramycin for P. aeruginosa infections, with therapy adjustments guided by individualized susceptibility reports. Notably, 19/46 E. coli isolates (41.3%) produced extended-spectrum β-lactamases (ESBLs), conferring resistance to multiple β-lactams and complicating therapeutic management [ 11 ] . For ESBL-producing strains, treatment should be stratified by infection severity: mild-to-moderate infections may respond to β-lactam/β-lactamase inhibitors (e.g., cefoperazone-sulbactam), while severe infections warrant carbapenems to mitigate antibiotic misuse and resistance dissemination. Although anaerobic pathogens were undetected in this study—potentially due to methodological constraints—their established role in surgical abdominal infections necessitates further investigation [ 12 ] . This study has several limitations. First, its single-center design and relatively small sample size (n = 70) limit the statistical power and the generalizability of the findings. The bacterial spectrum and resistance profiles observed may not fully represent those in other geographic regions or healthcare settings with different patient populations and antibiotic prescribing practices. Second, the study focused on purulent specimens from postoperative infections, which may not capture the entire microbial etiology of acute appendicitis, particularly in non-perforated or early cases. Third, the absence of anaerobic culture data, as acknowledged, is a methodological constraint that prevents a comprehensive assessment of polymicrobial infections. Future large-scale, multicenter studies incorporating anaerobic detection and molecular epidemiology are warranted to validate and extend these findings, and to better inform regional empirical therapy guidelines. Postoperative infections complicate 45–83% of appendicitis cases, with rising antimicrobial resistance exacerbating treatment challenges. Mortality from severe intra-abdominal infections exceeds 20% despite broad-spectrum antibiotic use [ 13 ] . Thus, early intervention, rigorous specimen testing, and susceptibility-guided therapy are critical to reducing multidrug-resistant infections, healthcare costs, and mortality. While appendectomy remains definitive management, rational antimicrobial stewardship is indispensable. By delineating pathogen profiles and resistance dynamics, this study provides evidence-based strategies to optimize pediatric appendicitis care. 5. Conclusion This study demonstrates that Gram-negative bacteria, particularly Escherichia coli, represent the predominant pathogens in pediatric acute appendicitis, with a considerable proportion (41.3%) being ESBL-positive. Antibiotic selection should be guided by susceptibility profiles, particularly avoiding agents with high resistance rates. Based on the susceptibility patterns observed in our cohort, ESBL-producing strains should be managed with severity-adjusted regimens, utilizing β-lactam/β-lactamase inhibitors for mild infections and carbapenems for severe cases. These recommendations are specific to the epidemiological context of this study and should be adapted according to local antimicrobial resistance data. Although these findings contribute to the evidence base for tailored antimicrobial therapy, the single-center design and limited sample size may restrict the generalizability of the results. Further validation through multicenter studies and the integration of rapid diagnostic technologies are essential to refine clinical practice. Declarations Data Availability statement The datasets generated and/or analysed during the current study are not publicly available due to patient privacy and confidentiality concerns but are available from the corresponding author on reasonable request. CRediT author statement Yan Peng : Conceptualization, Methodology, Investigation, Visualization, Funding acquisition, Writing- Original draft preparation, Writing- Reviewing and Editing. Mengqi Li : Data curation, Funding acquisition, Writing- Original draft preparation, Writing- Reviewing and Editing, Project administration. Huaiwei Zhang: Data curation, Writing- Reviewing and Editing. Funding This study was supported by Natural Science Research Project of Fuyang Normal University (2022KYQD0016), Fuyang Normal University Outstanding Talent Education and Training Program (2025ZYRCJH02), Fuyang Normal University Practice Education Special Project (2025SJYRZX11), Fuyang Normal University Medical Research Special Project (2024FYNUEY19, 2024FYNUFN02, 2025FYNUZL04, 2025FSKJ57). Conflicts of interest The authors declare that there are no competing interests associated with the manuscript. Compliance with Ethical Standards The research protocol was approved by the Medical Ethics Special Committee of Fuyang Normal University (HSR-26-000251). Declaration of generative AI and AI-assisted technologies in the manuscript preparation process During the preparation of this work the author(s) used ChatGPT in order to proofread. After using this tool, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article. References Beltzer Christian,Haas Frank,Jahn LenaSofia, et al. Outcome of Laparoscopic Versus Open Appendectomy for Acute Appendicitis-Results of a Propensity Score Matching Analysis of 542 Patients and Consequences for the Military Surgeon.[J]. Military Medicine, 2023, 189(3-4): e632-e637. Hodge Sarah VL,Mickiewicz Beata,Lau Matthew, et al. Novel molecular biomarkers and diagnosis of acute appendicitis in children[J]. Biomarkers in Medicine, 2021, 15(12): 1055-1065. Pata Francesco,Nardo Bruno,Ielpo Benedetto, et al. Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis.[J]. Surgery, 2023, 174(6): 1292-1301. William Bonadio,Syeda Shahid,Lior Vardi, et al. A pre-operative clinical scoring system to distinguish perforation risk with pediatric appendicitis[J]. Journal of Pediatric Surgery, 2018, 53(3): 441-445. Maya Paran,Yael Dreznik,Moussa Totah, et al. Diagnostic challenges of acute appendicitis in preschool children: A comprehensive case-control study.[J]. Journal of Paediatrics and Child Health, 2024, 61(3): 369-375. Omar Rashid,Jalila Qayoom,Syed Khurshid, et al. Microbiological Profile and the Antimicrobial Susceptibility Pattern in Endotracheal tube tip Culture/ Endotracheal Aspirates of Mechanically Ventilated Patients at a Tertiary Care Hospital in Kashmir Valley: A Cross Sectional Study[J]. Journal of Advances in Medicine and Medical Research, 2022, 34(4): 26-31. Department of Paediatric Surgery,School of Clinical Medicine,Faculty of Health Sciences, et al. Correlation of white cell count and CRP in acute appendicitis in paediatric patients.[J]. South African Journal of Surgery. Suid-afrikaanse Tydskrif Vir Chirurgie, 2019, 57(4): 40. Kengo Inagaki,Chad Blackshear,Michael W. Morris, et al. Pediatric Appendicitis–Factors Associated With Surgical Approach, Complications, and Readmission[J]. Journal of Surgical Research, 2020, 246: 395-402. Parmanik Ankita,Das Soumyajit,Kar Biswakanth, et al. Current Treatment Strategies Against Multidrug-Resistant Bacteria: A Review[J]. Current Microbiology, 2022, 79(12): 388. Abate Bane Shewaye,Kaleb Assefa Berhane,Samrawit Solomon, et al. Crohn's disease presenting as acute appendicitis: Case series.[J]. International Journal of Surgery Case Reports, 2025, 134: 111784. Chun He,Shuangshuang Wu,Xu Wang, et al. Surveillance and Resistance of Community-Onset Extended-Spectrum β-Lactamase-Producing Escherichia coli and Klebsiella pneumonia in Oral and Maxillofacial Surgery Site Infections.[J]. Surgical Infections, 2024, 25(3): 247-252. Executive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021: Erratum[J]. Critical Care Medicine, 2022, 50(4): e413-e414. Robert A Bonomo,Anthony W Chow,Morven S Edwards, et al. 2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation in Adults, Children, and Pregnant People.[J]. Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America, 2024, 79(3): S81-S87. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-9428869","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":626707895,"identity":"80b5dcfc-5ded-41bd-8062-42bd15b8d102","order_by":0,"name":"Yan Peng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIie3OvQrCMBDA8ZNCs5zoGAT1FSqBqvRl2sUuqbNDh0ydoj6Bz2Ih0Kk6dxAcBBc76CJO4kf3WDfB/DnIDfeDAJhMP1yPiPdr1ScM029JIGuTIZmrE8a7UNIoozDzAkE2qZaM5XbiYXaMJJ1OKORhIHDqa4lTcJehraI15S5tJCoQFB092ZdPclchvsm9DimQHZqJ8isiapCx5G5jtVADiSUb+VnIEuR6MiQ5O5dX1UfCB8U59rpLkn/4GIDdwdfW9gGeA7b2viLW5fbaWumnW5PJZPrXHhaMQrB8E7JVAAAAAElFTkSuQmCC","orcid":"","institution":"Fuyang Normal University","correspondingAuthor":true,"prefix":"","firstName":"Yan","middleName":"","lastName":"Peng","suffix":""},{"id":626707897,"identity":"0a7f7679-2d0c-48fc-9807-2f5ea389c238","order_by":1,"name":"Mengqi Li","email":"","orcid":"","institution":"Fuyang Normal University","correspondingAuthor":false,"prefix":"","firstName":"Mengqi","middleName":"","lastName":"Li","suffix":""},{"id":626707901,"identity":"43583f2c-347c-4119-a5c7-e4e6ec81ae03","order_by":2,"name":"Huaiwei Zhang","email":"","orcid":"","institution":"Fuyang Normal University","correspondingAuthor":false,"prefix":"","firstName":"Huaiwei","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2026-04-15 15:29:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9428869/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9428869/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107520299,"identity":"654202f6-cb33-45f4-bc49-f3eafeb9e810","added_by":"auto","created_at":"2026-04-22 08:59:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":415588,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9428869/v1/f654a1af-f622-4f14-b4d3-82fcacc46274.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bacterial Culture and Antimicrobial Susceptibility Analysis of Purulent Specimens in Pediatric Acute Appendicitis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAcute appendicitis is among the most common surgical emergencies in the pediatric population. It typically presents with periumbilical pain that migrates to the right lower quadrant, accompanied by nausea, vomiting, diarrhea, and fever\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In recent years, the incidence of pediatric acute appendicitis has risen, potentially due to changes in lifestyle and dietary habits\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The anatomical and physiological characteristics of children often lead to rapid disease progression and severe complications such as perforation and peritonitis. Thus, prompt diagnosis and appropriate intervention are critical for improving outcomes. Current management primarily involves appendectomy combined with antimicrobial therapy to control infection and facilitate recovery\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, selecting optimal antimicrobial regimens remains challenging. Variations in regional bacterial epidemiology and resistance patterns often lead to inconsistent efficacy with empirical antibiotic use, which may contribute to treatment failure, increased healthcare costs, and antimicrobial resistance\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Therefore, understanding local microbiological profiles and susceptibility patterns is essential for rational antibiotic selection.\u003c/p\u003e \u003cp\u003eThis study aims to investigate the bacterial distribution and antimicrobial resistance patterns in purulent specimens from pediatric acute appendicitis cases through microbiological culture and susceptibility testing. The results are intended to support evidence-based antibiotic selection, improve therapeutic efficacy, reduce inappropriate antibiotic use, and decrease complication rates. Furthermore, this work provides a foundation for future research aimed at enhancing diagnostic and treatment strategies for pediatric acute appendicitis.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Population and Specimen Collection\u003c/h2\u003e \u003cp\u003eSeventy pediatric patients (48 males, 22 females; age range 3\u0026ndash;12 years, mean 7.5 years) diagnosed with acute appendicitis were consecutively enrolled between January 2024 and January 2025 at Fuyang Maternity and Child Health Care Hospital. All patients met the diagnostic criteria for acute appendicitis and developed postoperative incision infections as defined by the \u003cem\u003eHospital-Acquired Infection Diagnostic Standards (Trial Version)\u003c/em\u003e\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Patients with a history of abdominal surgery or concurrent infections at admission were excluded. The study was approved by the institutional ethics committee, and written informed consent was obtained from legal guardians. All methods were performed in accordance with the relevant guidelines and regulations (e.g., the Declaration of Helsinki).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Instruments and Reagents\u003c/h2\u003e \u003cp\u003eMicrobiological analyses were performed using the VITEK\u0026reg; 2 Compact automated system (bioM\u0026eacute;rieux, France) with GP/GN identification cards and GP67/GN13 susceptibility test cards. Blood agar, MacConkey agar, and chocolate agar plates were supplied by Hefei Tianda Diagnostic Reagents Co., Ltd. Quality control strains (Escherichia coli ATCC\u0026reg; 25922 and Pseudomonas aeruginosa ATCC\u0026reg; 27853) were obtained from the National Center for Clinical Laboratories. All reagents were used within their expiration dates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Experimental Procedures\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Specimen Collection and Processing\u003c/h2\u003e \u003cp\u003ePus samples were aseptically collected using sterile swabs during appendectomy. Specimens were transported in sterile containers to the clinical microbiology laboratory within 60 minutes. They were inoculated onto blood and MacConkey agar plates using a quadrant streak method and incubated at 35\u0026deg;C for 18\u0026ndash;24 hours.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Bacterial Identification\u003c/h2\u003e \u003cp\u003eSingle colonies were purified and subjected to Gram staining. Gram-positive and Gram-negative isolates were identified using GP and GN cards, respectively, on the VITEK\u0026reg; 2 Compact system following standard clinical microbiology protocols.\u003c/p\u003e \u003cp\u003e\u003cb\u003e2.3.3 Antimicrobial Susceptibility Testing\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMinimum inhibitory concentrations (MICs) were determined using broth microdilution method. Extended-spectrum β-lactamase (ESBL) production was confirmed through double-disk synergy testing. All procedures and interpretive criteria complied with current Clinical and Laboratory Standards Institute (CLSI) guidelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4 Statistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS version 25.0 (IBM Corp.). Categorical variables are expressed as frequencies, and continuous variables as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Distribution of Appendicitis Subtypes\u003c/h2\u003e \u003cp\u003eAmong the 70 cases, pathological subtypes included: acute appendicitis with peritonitis (67.1%, n\u0026thinsp;=\u0026thinsp;47), acute simple appendicitis (12.9%, n\u0026thinsp;=\u0026thinsp;9), acute suppurative appendicitis with diffuse peritonitis (7.1%, n\u0026thinsp;=\u0026thinsp;5), acute appendicitis with perforation (5.7%, n\u0026thinsp;=\u0026thinsp;4), acute appendicitis perforation with diffuse peritonitis (5.7%, n\u0026thinsp;=\u0026thinsp;4), and acute gangrenous appendicitis with perforation (1.4%, n\u0026thinsp;=\u0026thinsp;1) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathological subtypes of acute appendicitis (n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Appendicitis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Cases \u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute appendicitis with peritonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute simple appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute suppurative appendicitis with diffuse peritonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute appendicitis with perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute appendicitis with perforation and diffuse peritonitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute gangrenous appendicitis with perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Pathogen Distribution\u003c/h2\u003e \u003cp\u003eMicrobiological analysis identified 62 pathogenic isolates from 70 specimens, yielding a positive detection rate of 88.6%. Gram-positive bacteria accounted for 1.6% (1 isolate: \u003cem\u003eEnterococcus avium\u003c/em\u003e), while Gram-negative organisms predominated at 98.3% (61 isolates). The latter comprised \u003cem\u003eEscherichia coli\u003c/em\u003e (74.2%, 46 isolates), \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (14.5%, 9 isolates), \u003cem\u003eProteus mirabilis\u003c/em\u003e (3.2%, 2 isolates), \u003cem\u003eComamonas testosteroni\u003c/em\u003e (4.8%, 3 isolates), and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (1.6%, 1 isolate) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathogenic bacteria isolated from purulent specimens (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathogen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Strains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEscherichia coli\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudomonas aeruginosa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComamonas testosteroni\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProteus mirabilis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKlebsiella pneumoniae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnterococcus avium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Antimicrobial Susceptibility of Predominant Pathogens\u003c/h2\u003e \u003cp\u003eAntibiotic susceptibility testing revealed distinct resistance patterns in \u003cem\u003eEscherichia coli\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;46) and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;9). \u003cem\u003eE. coli\u003c/em\u003e demonstrated very high susceptibility to amikacin, imipenem, tigecycline, ertapenem, cefoperazone, and piperacillin, with resistance rates ranging from 0% to 4.3%. Conversely, elevated resistance (\u0026gt;\u0026thinsp;40%) was observed against trimethoprim-sulfamethoxazole, cefuroxime sodium, ceftriaxone, cefuroxime axetil, and levofloxacin.\u003c/p\u003e \u003cp\u003e \u003cem\u003eP. aeruginosa\u003c/em\u003e exhibited 100% susceptibility to amikacin, imipenem, cefepime, ceftazidime, cefoperazone, levofloxacin, piperacillin, tobramycin, meropenem, and ciprofloxacin (resistance rate 0%). However, intermediate susceptibility was observed for ticarcillin (2 isolates) and colistin (1 isolate). The absence of resistant \u003cem\u003eP. aeruginosa\u003c/em\u003e strains in this cohort may be attributed to the limited sample size (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAntimicrobial susceptibility of Escherichia coli (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResistance rate (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmikacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoxitin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefepime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrimethoprim-sulfamethoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTigecycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmoxicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErtapenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefuroxime sodium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftriaxone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoperazone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiperacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefuroxime axetil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote: S\u0026thinsp;=\u0026thinsp;Susceptible, R\u0026thinsp;=\u0026thinsp;Resistant, I\u0026thinsp;=\u0026thinsp;Intermediate\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAntimicrobial susceptibility of Pseudomonas aeruginosa (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntibiotic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResistance rate (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmikacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefepime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefoperazone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiperacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColistin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTicarcillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTobramycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeropenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiprofloxacin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote: S\u0026thinsp;=\u0026thinsp;Susceptible, R\u0026thinsp;=\u0026thinsp;Resistant, I\u0026thinsp;=\u0026thinsp;Intermediate\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Extended-Spectrum β-Lactamase (ESBL) Production Among \u003cem\u003eEscherichia coli\u003c/em\u003e Isolates\u003c/h2\u003e \u003cp\u003eAmong the 46 \u003cem\u003eEscherichia coli\u003c/em\u003e isolates, ESBL-producing strains were identified in 19 cases (41.3%), with the remaining 27 isolates (58.7%) classified as non-ESBL-producing (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eESBL production in Escherichia coli isolates (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESBL production\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESBL-producing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-ESBL-producing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eAcute appendicitis, one of the most common surgical emergencies in general surgery, typically manifests with periumbilical or epigastric pain that migrates and localizes to McBurney's point in the right lower quadrant, accompanied by fixed tenderness on palpation. Although its incidence in pediatric populations is lower than in adults, the condition often progresses more rapidly with higher risks of complications such as perforation and diffuse peritonitis, necessitating heightened clinical vigilance\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. This study systematically analyzed bacterial culture and antimicrobial susceptibility profiles of purulent secretions from 70 pediatric acute appendicitis cases, elucidating pathogen distribution patterns and resistance characteristics to inform evidence-based antibiotic selection.\u003c/p\u003e \u003cp\u003eAmong the 70 specimens, 62 pathogenic isolates were identified (detection rate: 88.6%). Gram-negative bacteria predominated (98.3%), with \u003cem\u003eEscherichia coli\u003c/em\u003e (74.2%) and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (14.5%) constituting the primary pathogens. These findings align with studies by You et al.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, confirming Gram-negative bacteria, particularly \u003cem\u003eE. coli\u003c/em\u003e, as predominant etiological agents in pediatric acute appendicitis. Gram-positive bacteria were rare (1.6%, \u003cem\u003eEnterococcus avium\u003c/em\u003e). Antimicrobial susceptibility testing revealed substantial resistance heterogeneity: \u003cem\u003eE. coli\u003c/em\u003e exhibited high resistance (\u0026gt; 40%) to cefuroxime sodium, ceftriaxone, cefuroxime axetil, and levofloxacin while demonstrating marked susceptibility (\u0026gt; 70%) to amikacin, imipenem, tigecycline, ertapenem, cefoperazone, and piperacillin. Conversely, \u003cem\u003eP. aeruginosa\u003c/em\u003e showed 100% susceptibility to amikacin, imipenem, cefepime, ceftazidime, cefoperazone, levofloxacin, piperacillin, tobramycin, meropenem, and ciprofloxacin, consistent with findings by Zhuang et al. and Ye et al.\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. These results suggest prioritizing ceftazidime or amoxicillin for \u003cem\u003eE. coli\u003c/em\u003e infections, and piperacillin or tobramycin for \u003cem\u003eP. aeruginosa\u003c/em\u003e infections, with therapy adjustments guided by individualized susceptibility reports.\u003c/p\u003e \u003cp\u003eNotably, 19/46 \u003cem\u003eE. coli\u003c/em\u003e isolates (41.3%) produced extended-spectrum β-lactamases (ESBLs), conferring resistance to multiple β-lactams and complicating therapeutic management\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. For ESBL-producing strains, treatment should be stratified by infection severity: mild-to-moderate infections may respond to β-lactam/β-lactamase inhibitors (e.g., cefoperazone-sulbactam), while severe infections warrant carbapenems to mitigate antibiotic misuse and resistance dissemination. Although anaerobic pathogens were undetected in this study—potentially due to methodological constraints—their established role in surgical abdominal infections necessitates further investigation\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, its single-center design and relatively small sample size (n = 70) limit the statistical power and the generalizability of the findings. The bacterial spectrum and resistance profiles observed may not fully represent those in other geographic regions or healthcare settings with different patient populations and antibiotic prescribing practices. Second, the study focused on purulent specimens from postoperative infections, which may not capture the entire microbial etiology of acute appendicitis, particularly in non-perforated or early cases. Third, the absence of anaerobic culture data, as acknowledged, is a methodological constraint that prevents a comprehensive assessment of polymicrobial infections. Future large-scale, multicenter studies incorporating anaerobic detection and molecular epidemiology are warranted to validate and extend these findings, and to better inform regional empirical therapy guidelines.\u003c/p\u003e \u003cp\u003ePostoperative infections complicate 45–83% of appendicitis cases, with rising antimicrobial resistance exacerbating treatment challenges. Mortality from severe intra-abdominal infections exceeds 20% despite broad-spectrum antibiotic use\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Thus, early intervention, rigorous specimen testing, and susceptibility-guided therapy are critical to reducing multidrug-resistant infections, healthcare costs, and mortality. While appendectomy remains definitive management, rational antimicrobial stewardship is indispensable. By delineating pathogen profiles and resistance dynamics, this study provides evidence-based strategies to optimize pediatric appendicitis care.\u003c/p\u003e "},{"header":"5. Conclusion","content":"\u003cp\u003eThis study demonstrates that Gram-negative bacteria, particularly Escherichia coli, represent the predominant pathogens in pediatric acute appendicitis, with a considerable proportion (41.3%) being ESBL-positive.\u003c/p\u003e\u003cp\u003eAntibiotic selection should be guided by susceptibility profiles, particularly avoiding agents with high resistance rates. Based on the susceptibility patterns observed in our cohort, ESBL-producing strains should be managed with severity-adjusted regimens, utilizing β-lactam/β-lactamase inhibitors for mild infections and carbapenems for severe cases. These recommendations are specific to the epidemiological context of this study and should be adapted according to local antimicrobial resistance data.\u003c/p\u003e\u003cp\u003eAlthough these findings contribute to the evidence base for tailored antimicrobial therapy, the single-center design and limited sample size may restrict the generalizability of the results. Further validation through multicenter studies and the integration of rapid diagnostic technologies are essential to refine clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to patient privacy and confidentiality concerns but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT author statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYan Peng\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Conceptualization, Methodology, Investigation, Visualization, Funding acquisition, Writing- Original draft preparation, Writing- Reviewing and Editing. \u003cstrong\u003eMengqi Li\u003c/strong\u003e: Data curation, Funding acquisition, Writing- Original draft preparation, Writing- Reviewing and Editing, Project administration.\u0026nbsp;\u003cstrong\u003eHuaiwei Zhang:\u003c/strong\u003e Data curation, Writing- Reviewing and Editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Natural Science Research Project of Fuyang Normal University (2022KYQD0016), Fuyang Normal University Outstanding Talent Education and Training Program (2025ZYRCJH02), Fuyang Normal University Practice Education Special Project (2025SJYRZX11), Fuyang Normal University Medical Research Special Project (2024FYNUEY19, 2024FYNUFN02, 2025FYNUZL04, 2025FSKJ57).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no competing interests associated with the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research protocol was approved by the Medical Ethics Special Committee of Fuyang Normal University (HSR-26-000251).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted technologies in the manuscript preparation process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work the author(s) used ChatGPT in order to proofread. After using this tool, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBeltzer Christian,Haas Frank,Jahn LenaSofia, et al. Outcome of Laparoscopic Versus Open Appendectomy for Acute Appendicitis-Results of a Propensity Score Matching Analysis of 542 Patients and Consequences for the Military Surgeon.[J]. Military Medicine, 2023, 189(3-4): e632-e637.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eHodge Sarah VL,Mickiewicz Beata,Lau Matthew, et al. Novel molecular biomarkers and diagnosis of acute appendicitis in children[J]. Biomarkers in Medicine, 2021, 15(12): 1055-1065.\u003c/li\u003e\n \u003cli skip=\"true\"\u003ePata Francesco,Nardo Bruno,Ielpo Benedetto, et al. Endoscopic retrograde appendicitis therapy versus appendectomy or antibiotics in the modern approach to uncomplicated acute appendicitis: A systematic review and meta-analysis.[J]. Surgery, 2023, 174(6): 1292-1301.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eWilliam Bonadio,Syeda Shahid,Lior Vardi, et al. A pre-operative clinical scoring system to distinguish perforation risk with pediatric appendicitis[J]. Journal of Pediatric Surgery, 2018, 53(3): 441-445.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eMaya Paran,Yael Dreznik,Moussa Totah, et al. Diagnostic challenges of acute appendicitis in preschool children: A comprehensive case-control study.[J]. Journal of Paediatrics and Child Health, 2024, 61(3): 369-375.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eOmar Rashid,Jalila Qayoom,Syed Khurshid, et al. Microbiological Profile and the Antimicrobial Susceptibility Pattern in Endotracheal tube tip Culture/ Endotracheal Aspirates of Mechanically Ventilated Patients at a Tertiary Care Hospital in Kashmir Valley: A Cross Sectional Study[J]. Journal of Advances in Medicine and Medical Research, 2022, 34(4): 26-31.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eDepartment of Paediatric Surgery,School of Clinical Medicine,Faculty of Health Sciences, et al. Correlation of white cell count and CRP in acute appendicitis in paediatric patients.[J]. South African Journal of Surgery. Suid-afrikaanse Tydskrif Vir Chirurgie, 2019, 57(4): 40.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eKengo Inagaki,Chad Blackshear,Michael W. Morris, et al. Pediatric Appendicitis\u0026ndash;Factors Associated With Surgical Approach, Complications, and Readmission[J]. Journal of Surgical Research, 2020, 246: 395-402.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eParmanik Ankita,Das Soumyajit,Kar Biswakanth, et al. Current Treatment Strategies Against Multidrug-Resistant Bacteria: A Review[J]. Current Microbiology, 2022, 79(12): 388.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eAbate Bane Shewaye,Kaleb Assefa Berhane,Samrawit Solomon, et al. Crohn\u0026apos;s disease presenting as acute appendicitis: Case series.[J]. International Journal of Surgery Case Reports, 2025, 134: 111784.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eChun He,Shuangshuang Wu,Xu Wang, et al. Surveillance and Resistance of Community-Onset Extended-Spectrum \u0026beta;-Lactamase-Producing Escherichia coli and Klebsiella pneumonia in Oral and Maxillofacial Surgery Site Infections.[J]. Surgical Infections, 2024, 25(3): 247-252.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eExecutive Summary: Surviving Sepsis Campaign: International Guidelines for the Management of Sepsis and Septic Shock 2021: Erratum[J]. Critical Care Medicine, 2022, 50(4): e413-e414.\u003c/li\u003e\n \u003cli skip=\"true\"\u003eRobert A Bonomo,Anthony W Chow,Morven S Edwards, et al. 2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Risk Assessment, Diagnostic Imaging, and Microbiological Evaluation in Adults, Children, and Pregnant People.[J]. Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America, 2024, 79(3): S81-S87.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"Microbial distribution, Antimicrobial susceptibility, Antibiotic resistance, Empirical antibiotic therapy","lastPublishedDoi":"10.21203/rs.3.rs-9428869/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9428869/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTo characterize microbial distribution and antimicrobial susceptibility profiles in purulent specimens from pediatric acute appendicitis, guiding evidence-based antibiotic therapy optimization. In this prospective cohort study, intraoperative pus samples were collected from 70 consecutive pediatric patients undergoing appendectomy between January 2024 and January 2025. Bacterial identification was performed using the VITEK 2 Compact system. Antimicrobial susceptibility testing was conducted via broth microdilution for minimum inhibitory concentration (MIC) determination. Extended-spectrum β-lactamase (ESBL) production was confirmed using the Clinical and Laboratory Standards Institute (CLSI) double-disk synergy test. Pathogens were isolated from 88.6% of specimens (62/70), with Gram-negative bacteria predominating (98.3%, 61/62). The most common isolates were \u003cem\u003eEscherichia coli\u003c/em\u003e (74.2%, 46/62) and \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (14.5%, 9/62). \u003cem\u003eE. coli\u003c/em\u003e exhibited high susceptibility to amikacin (93.5%), imipenem (97.8%), and tigecycline (100%), but elevated resistance to co-trimoxazole (82.6%) and ceftriaxone (78.3%). All \u003cem\u003eP. aeruginosa\u003c/em\u003e isolates were susceptible to the tested antimicrobial agents. ESBL production was detected in 41.3% (19/46) of E. coli isolates. Gram-negative pathogens, particularly \u003cem\u003eE. coli\u003c/em\u003e and \u003cem\u003eP. aeruginosa\u003c/em\u003e, are the primary etiological agents in pediatric acute appendicitis. Empirical antibiotic therapy should prioritize agents effective against ESBL-producing strains, with carbapenems or aminoglycosides recommended as first-line options pending local susceptibility data.\u003c/p\u003e","manuscriptTitle":"Bacterial Culture and Antimicrobial Susceptibility Analysis of Purulent Specimens in Pediatric Acute Appendicitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 08:58:01","doi":"10.21203/rs.3.rs-9428869/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":"02889eac-4785-4464-acd5-2e3100873232","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvited","content":"","date":"2026-05-05T08:25:08+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":66697124,"name":"Health sciences/Diseases"},{"id":66697125,"name":"Health sciences/Medical research"},{"id":66697126,"name":"Biological sciences/Microbiology"}],"tags":[],"updatedAt":"2026-04-22T08:58:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 08:58:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9428869","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9428869","identity":"rs-9428869","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}
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