The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis

Background: Most protocols for the operative treatment of perforated append icitis use a routine culture. Although isolated studies suggest that routin e culture may not be necessary, these recommendations generally are not bas ed on objective outcome data. Methods: The authors reviewed the records of 308 children who underwent ope rative treatment for perforated appendicitis between 1988 and 1998 to deter mine if information gained from routine culture changes the management or i mproves outcome. Inclusion criteria included either gross or microscopic ev idence of appendiceal perforation. Results: Mean patient age was 7.5 years, 51% were boys, and there was no mo rtality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The us e of empiric antibiotics, as compared with modified antibiotics, was associ ated with a lower incidence of infectious complication, shorter fever durat ion, and decreased length of hospitalization. We also investigated the rela tionship between culture isolates and antibiotic regimens with regard to ou tcome. The utilization of antibiotics suitable for the respective culture i solate or organism sensitivity was associated with an increased incidence o f infectious complication and longer duration of both fever and length of h ospitalization. Finally, the initial culture correlated poorly with subsequ ent intraabdominal culture (positive predictive value, 11%). Conclusion: These outcome data strongly suggest that the practice of obtain ing routine cultures can be abandoned, and empiric broad spectrum antibioti c coverage directed at likely organisms is completely adequate for treatmen t of perforated appendicitis in children.