Postoperatieve antibioticaduur bij acute appendicitis
Uitgangsvraag
Wat is de optimale duur van antibiotica na een appendectomie voor een complexe appendicitis?
Aanbeveling
Behandel patiënten die een laparoscopische appendectomie ondergaan vanwege acute complexe appendicitis postoperatief standaard met 2 dagen antibiotica. Overweeg om kinderen jonger dan 8 jaar oud, immuungecompromiteerden, zwangeren en patiënten waar geen volledige source control is bereikt langer met antibiotica te behandelen.
Patiënten die een appendectomie ondergaan en tevens voldoen aan de criteria van sepsis dienen behandeld te worden volgens de richtlijn Sepsis.
Voor keuze van antibiotica wordt verwezen naar het lokale antibioticabeleid.
Overwegingen
Balans tussen gewenste en ongewenste effecten
Er is literatuuronderzoek verricht naar het effect van postoperatieve antibiotica voor korter dan drie dagen vergeleken met postoperatieve antibiotica voor drie dagen of langer in patiënten die een appendectomie ondergaan voor complexe acute appendicitis.
Er werden drie studies geïncludeerd, waarvan twee studies rapporteerden over dezelfde trial. Voor de cruciale uitkomstmaat morbiditeit werd geen klinisch relevant verschil gevonden in het voordeel van patiënten die drie dagen of meer postoperatieve antibiotica ontvingen. De bewijskracht voor deze cruciale uitkomstmaat was laag. Voor de cruciale uitkomstmaat mortaliteit werd geen klinisch relevant verschil gevonden. Voor deze uitkomstmaat was de bewijskracht matig.
Voor de belangrijke uitkomstmaat heropname werd geen klinisch relevant verschil gevonden. De bewijskracht voor deze uitkomstmaat was laag. Voor de belangrijke uitkomstmaat verblijfsduur in het ziekenhuis werd een verschil gevonden in het voordeel van de patiënten die korter dan drie dagen postoperatieve antibiotica ontvingen. De bewijskracht was ook voor deze uitkomstmaat laag. De belangrijke uitkomstmaat antibiotica resistentie werd niet gerapporteerd in de geïncludeerde studies. Voor de belangrijke uitkomstmaat radiologische of chirurgische interventies werden geen klinisch relevante verschillen gevonden, De bewijskracht was matig. Voor de belangrijke uitkomstmaat alle complicaties werden conflicterende resultaten gevonden, met een lage bewijskracht.
Van belang is om te realiseren dat bepaalde patiëntgroepen werden geëxcludeerd van deelname aan de studies die ten grondslag liggen aan deze aanbevelingen. Zo werden kinderen jonger dan 8 jaar, immuungecompromitteerden en zwangeren niet meegenomen in deze studies. In de APPIC studie was het aantal patiënten die een open appendectomie ondergingen (5%) mogelijk te laag om een uitspraak te doen.
Kwaliteit van bewijs
De overall kwaliteit van bewijs is laag. Dit betekent dat we onzeker zijn over het gevonden geschatte effect van de cruciale uitkomstmaten.
Er is afgewaardeerd vanwege ernstige:
- Risk of Bias: methodologische beperkingen (gebrek aan verhulling van de toewijzing, gebrek aan blindering, loss to follow-up, andere beperkingen).
- Inconsistentie: conflicterende resultaten.
- Imprecisie: onnauwkeurigheid, omdat het betrouwbaarheidsinterval de grens/beide grenzen van klinische relevantie overschrijdt.
Waarden en voorkeuren van patiënten (en eventueel hun naasten/verzorgers)
Voor patiënten met een complexe acute appendicitis die geopereerd dienen te worden zijn het voorkomen van complicaties, heropname, re-interventies en de totale duur van ziekenhuisopname belangrijke overwegingen bij het maken van een behandelkeuze. De voorkeur voor een specifieke behandeling kan echter sterk verschillen per patiënt. Alhoewel de kortere postoperatieve antibioticaduur gepaard ging met meer heropnames was de totale ziekenhuisopname duur inclusief heropname nog altijd korter dan voor de langere postoperatieve antibioticaduur. Naast deze argumenten kunnen antibiotica ook bijwerkingen geven. Uit de studie van van Wijkerslooth (2023) wordt duidelijk dat patiënten die korter antibiotica krijgen minder last ervaren van bijwerkingen. (Langer) antibioticagebruik verhoogt het risico op resistentieontwikkeling in de commensale flora wat een negatief effect kan hebben op behandelmogelijkheden van eventuele toekomstige infecties bij de patiënt.
Kostenaspecten
Op basis van de kosteneffectiviteitsanalyse (de Wijkerslooth, 2024) zijn er aanwijzingen dat een kortere duur van antibioticagebruik postoperatief leidt tot een kostenbesparing. Zowel wat betreft directe ziekenhuiskosten als maatschappelijke kosten is een kortere antibioticaduur kosteneffectief. De besparing komt met name voort uit een kortere opnameduur en gaat gepaard met een bedrag van ruim 600 euro per patiënt in de groep van kortere antibioticaduur. Het optreden van 1 extra infectieuze complicatie die kan ontstaan bij het behandelen van 50 patiënten met een kortere antibioticaduur staat tegenover een besparing van meer dan 30.000 euro.
Gelijkheid ((health) equity/equitable)
Het wel of niet voorschrijven van antibiotica na een appendectomie voor een complexe acute appendicitis heeft naar verwachting geen invloed op gezondheidsongelijkheid. Antibiotica die worden voorgeschreven in de ziekenhuissetting vallen binnen het basispakket van de zorgverzekering en worden doorgaans volledig vergoed. Nederlandse patiënten hebben geen aanvullende verzekering of eigen bijdrage nodig om toegang te krijgen tot deze behandeling.
Ook zijn er geen bijzondere vaardigheden vereist van patiënten om antibiotica te kunnen gebruiken, aangezien het gaat om intraveneuze toediening tijdens opname. De therapietrouw is in deze acute setting doorgaans hoog en er zijn geen aanwijzingen dat bepaalde patiëntgroepen (zoals laaggeletterden of mensen met beperkte gezondheidsvaardigheden) belemmeringen ondervinden.
Aanvaardbaarheid:
Ethische aanvaardbaarheid
Het gebruik van antibiotica na een appendectomie voor een complexe acute appendicitis is over het algemeen aanvaardbaar voor patiënten en zorgverleners. Antibiotica worden in de acute zorg breed toegepast en worden door patiënten doorgaans geaccepteerd als onderdeel van de behandeling, zeker wanneer het gaat om infectiepreventie of -bestrijding. Er zijn geen ethische bezwaren gerapporteerd met betrekking tot het al dan niet geven van antibiotica in deze context.
Vanuit het perspectief van antibioticaresistentie is het zorgvuldig en terughoudend voorschrijven van antibiotica maatschappelijk wenselijk en derhalve kan een kortere antibioticaduur in bepaalde patiëntengroepen als positief worden ervaren.
Duurzaamheid
Er is geen literatuur beschikbaar over de levenscyclusanalyse van antibiotica specifiek in het kader van gebruik bij acute appendicitis. Het is algemeen bekend dat de productie, distributie en het gebruik van antibiotica bijdraagt aan milieuvervuiling, onder andere via uitstoot bij productieprocessen, reststoffen in afvalwater en bevordering van antimicrobiële resistentie in het milieu. Deze effecten zijn echter sterk afhankelijk van het soort antibioticum, de dosering, en de duur van gebruik. Bij het afwegen van antibioticagebruik dient de mogelijke milieubelasting (nog) niet meegenomen te worden als bijkomend argument om gebruik te beperken. Wel is het positief te noemen als de postoperatieve duur van antibiotica verkort kan worden na een appendectomie voor een complexe acute appendicitis.
Haalbaarheid
Het voorschrijven van antibiotica na een appendectomie bij patiënten met complexe acute appendicitis vereist geen aanpassing van de huidige praktijk. De aanbevelingen sluiten aan bij het bestaande beleid in veel Nederlandse ziekenhuizen, echter is enkel de antibioticaduur korter. Uit de geïncludeerde studies blijkt dat het korter geven van antibiotica bij een geselecteerde patiëntengroep veilig en effectief kan zijn. Deze strategie vereist geen aanpassing van infrastructuur of aanvullende financiële middelen, maar wel goede klinische beoordeling van de ernst van de appendicitis.
Rationale van de aanbeveling: weging van argumenten voor en tegen de interventies
Er is geen klinisch relevant verschil aangetoond in postoperatieve complicaties, mortaliteit, heropnames en re-interventies tussen een korte en een langere duur van postoperatieve antibiotica. De bewijskracht is laag, maar het verkorten van antibioticagebruik verkort ziekenhuis opnameduur, inclusief de heropname duur en vermindert kosten.
Eindoordeel:
Sterke aanbeveling voor (Doen).
Onderbouwing
Postoperative antibiotics are recommended after appendectomy for complex appendicitis to prevent postoperative complications. However, the duration of this treatment is not uniform and varies between surgeons, hospitals and countries (differences in international guidelines).
Summary of Findings
Population: Patients undergoing appendectomy for complex acute appendicitis and therefore an indication for postoperative antibiotics
Intervention: Shorter than three days of postoperative antibiotics
Comparison: Three days or more of postoperative antibiotics
|
Outcome |
Study results and measurements |
Relative/Absolute effect estimates |
Certainty of the Evidence (Quality of evidence) |
Conclusions |
|
|
Three days or more of postoperative antibiotics |
Shorter than three days of postoperative antibiotics |
||||
|
(30 day) Morbidity (critical) |
Based on data from two studies |
De Wijkerslooth (2023) reported a RD of 0.02 (95% CI -0.01 to 0.06) for morbidity (infectious complications), in favor of postoperative antibiotics for five days. Saar (2019) reported a RD of 0.01 (95% CI -0.17 to 0.19) for morbidity (infectious complications), in favor of extended postoperative antibiotics. |
Low Due to serious risk of bias, due to serious imprecision1 |
Shorter than three days of postoperative antibiotics may result in little to no difference in morbidity when compared with three days or more of postoperative antibiotics in patients undergoing appendectomy for complex acute appendicitis.(De Wijkerslooth, 2023; Saar, 2019) |
|
|
Mortality (critical) |
Based on data from one study |
De Wijkerslooth (2023) reported a RR of 3.01 (95% CI 0.12 to 73.61) and a RD of 0.00 (95% CI -0.00 to 0.01), in favor of three days or more. |
Moderate Due to serious imprecision2 |
Shorter than three days of postoperative antibiotics likely results in little to no difference in mortality when compared with three days or more of postoperative antibiotics in patients undergoing appendectomy for complex acute appendicitis. (De Wijkerslooth, 2023) |
|
|
Readmission (important) |
Based on data from two studies |
De Wijkerslooth (2023) reported a RD of 0.06 (95% CI 0.02 to 0.09), in favor of postoperative antibiotics for five days. Saar (2019) reported a RD of 0.00 (95% CI -0.11 to 0.12). |
Low Due to serious risk of bias, due to serious inconsistency3 |
Shorter than three days of postoperative antibiotics may result in little to no difference in readmission when compared with three days or more of postoperative antibiotics in patients undergoing appendectomy for complex acute appendicitis. (De Wijkerslooth, 2023; Saar, 2019) |
|
|
Costs (important) |
Based on data from one study |
De Wijkerslooth (2024) reported a MD of -704 euros (95% CI -923.07 to -484.93) for direct health care costs, in favor of shorter than three days. De Wijkerslooth (2024) reported a MD of -625 euros (95% CI -965.39 to -284.61) for overall societal costs, in favor of shorter than three days. |
The certainty of the evidence was not assessed for this outcome. |
|
|
|
Length of hospital stay (important) |
Based on data from two studies |
De Wijkerslooth (2023) reported a median difference of -2.0 days (95% CI -2.00 to -2.00), in favor of shorter than three days. Saar (2019) reported a MD of -20 hours (95% CI -36.24 to -3.76), in favor of shorter than three days. |
Low Due to serious risk of bias, due to serious imprecision4 |
Shorter than three days of postoperative antibiotics may reduce length of hospital stay when compared with three days or more of postoperative antibiotics in patients undergoing appendectomy for complex acute appendicitis. (De Wijkerslooth, 2023; Saar, 2019) |
|
|
Antibiotic resistance (important) |
No data |
None of the included studies reported the outcome measure antibiotics resistance. |
No GRADE |
No evidence was found regarding the effect of shorter than three days of postoperative antibiotics on antibiotics resistance when compared with three days or more of postoperative antibiotics in patients undergoing appendectomy for complex acute appendicitis. |
|
|
Radiological or surgical interventions (important) |
Based on data from two studies |
De Wijkerslooth (2023) reported a RD of 0.02 (95% CI -0.01 to 0.05), in favor of postoperative antibiotics for five days. Saar (2019) reported a RD of 0.00 (95% CI -0.09 to 0.10). |
Moderate Due to serious imprecision5 |
Shorter than three days of postoperative antibiotics likely results in little to no difference in radiological or surgical interventions when compared with three days or more of postoperative antibiotics in patients undergoing appendectomy for complex appendicitis. (De Wijkerslooth, 2023; Saar, 2019) |
|
|
Any complications (important) |
Based on data from two studies |
De Wijkerslooth (2023) reported a RD of 0.04 (95% CI -0.01 to 0.09), in favor of postoperative antibiotics for five days. Saar (2019) reported a RD of -0.11 (95% CI -0.30 to 0.07), in favor of short postoperative antibiotics. |
Low Due to serious risk of bias, due to serious inconsistency6 |
Shorter than three days of postoperative antibiotics may result in little to no difference in any complications when compared with three days or more of postoperative antibiotics in patients undergoing appendectomy for complex appendicitis. (De Wijkerslooth, 2023; Saar, 2019) |
|
1. Risk of bias: serious. Due to lack of allocation concealment, lack of blinding, frequent loss-to-follow-up, other limitations.
Imprecision: serious. Due to overlap of the limits of the 95% confidence interval with the minimal clinically important difference.
2. Imprecision: serious. Due to very small number of events.
3. Risk of bias: serious. Due to lack of allocation concealment, lack of blinding, frequent loss-to-follow-up, other limitations.
Inconsistency: serious. Due to conflicting results.
4. Risk of bias: serious. Due to lack of allocation concealment, lack of blinding, frequent loss-to-follow-up, other limitations.
Imprecision: serious. Due to overlap of the lower limit of the 95% confidence interval with the minimal clinically important difference.
5. Imprecision: serious. Due to overlap of the upper limit of the 95% confidence interval with the minimal clinically important difference.
6. Risk of bias: serious. Due to lack of allocation concealment, lack of blinding, frequent loss-to-follow-up, other limitations.
Inconsistency: serious. Due to conflicting results.
Description of studies
A total of three studies were included in the analysis of the literature. Important study characteristics and results are summarized in table 2. The assessment of the risk of bias is summarized in the risk of bias tables (under the tab ‘Evidence tabellen’).
De Wijkerslooth (2023) performed an open-label, randomized, controlled trial powered for non-inferiority to compare two days versus five days of postoperative antibiotics in patients with complex appendicitis who underwent appendectomy (APPIC trial). Patients with acute appendicitis who were older than eight years, had an ASA classification of I-III and a diagnosis of complex appendicitis were eligible for trial participation. Exclusion criteria were: being pregnant, being immunocompromised, a contraindication to the trial drugs, and if adequate source control could not be reached during surgery. In total, 15 hospitals in The Netherlands participated in the trial.
De Wijkerslooth (2024) performed a cost-analysis of the APPIC trial (De Wijkerslooth, 2023).
Saar (2019) performed a prospective, single-center, open-label randomized controlled trial to investigate noninferiority of a short and fixed (24h) antibiotic administration compared to extended treatment after source control in complex appendicitis. The average length of antibiotic therapy in the extended group was 6 ± 3 days. Patients who were eighteen years or older, with acute appendicitis based on clinical diagnosis supported by laboratory markers, ultrasound and/or CT were eligible for trial participation. Exclusion criteria were: age under eighteen years, pregnancy, cognitive impairment, diabetes, immunodeficiency, ongoing chemotherapy or radiotherapy for any oncological disease, radical treatment of an oncological disease within five years, penicillin allergy, presence of a mechanical heart valve or synthetic vascular implants or grafts, and grade 1 or grade 5 appendicitis (DSS).
Table 2. Characteristics of included studies
|
Study |
Participants |
Comparison |
Follow-up |
Outcome measures |
Comments |
Risk of bias (per outcome measure)* |
|
Individual studies |
||||||
|
De Wijkerslooth, 2023 (APPIC trial) |
N at baseline Intervention: 502 Control: 503
Age (mean, range) Intervention: 51 years (31-62) Control: 52 years (30-64)
Sex (male/ female) Intervention: 285/217 Control: 286/217
Duration of symptoms Intervention: 2.0 days (1.0-3.0) Control: 2.0 days (1.0-2.8)
Intravenous antibiotics in emergency department or ward Intervention: 150 (30%) Control: 151 (30%) |
Intervention: 2 days of postoperative antibiotics after appendectomy
Control: 5 days of postoperative antibiotics after appendectomy |
90 days after appendectomy |
Morbidity: Intra-abdominal abscess, Surgical site infection
Mortality
Any complication
Re-interventions
Hospital re-admission
Total length of stay |
Funding: The Netherlands Organization for Health Research and Development
Conflicts of interest: no competing interests declared |
Some concerns (loss to follow-up, other bias) |
|
De Wijkerslooth, 2024 (APPIC trial) |
N at baseline Intervention: 502 Control: 503
Age (mean, range) Intervention: 51 years (31-62) Control: 52 years (30-64)
Sex (male/ female) Intervention: 285/217 Control: 286/217
Duration of symptoms Intervention: 2.0 days (1.0-3.0) Control: 2.0 days (1.0-2.8)
Intravenous antibiotics in emergency department or ward Intervention: 150 (30%) Control: 151 (30%) |
Intervention: 2 days of postoperative antibiotics after appendectomy
Control: 5 days of postoperative antibiotics after appendectomy |
90 days after appendectomy |
Overall societal costs
Direct health care costs
|
Funding: The Netherlands Organization for Health Research and Development
Conflicts of interest: no competing interests declared |
Some concerns (loss to follow-up, other bias) |
|
Saar, 2019 |
N at baseline Intervention: 39 Control: 41
Age (mean, SD) Intervention: 44.2 ± 15.2 years Control: 45.8 ± 15.3 years
Sex (male) Intervention: 56.4% Control: 63.4%
Time from onset of symptoms to surgery: Intervention: 43.2 ± 31.2 hours Control: 48.4 ± 44.3 hours
Average length of antibiotic treatment: Intervention: <24 hours Control: 6 ± 3 days |
Intervention: Short antibiotic therapy (<24h)
Control: Extended antibiotic therapy (>24h) |
30 days (follow-up phone call) |
Hospital length of stay
Morbidity: Superficial/deel surgical site infection
Organ/space surgical site infection
Any Clavien-Dindo complication
Postoperative ileus
Readmitted patients
Antimicrobial therapy
Percutaneous drainage + antimicrobial therapy |
The authors declare no conflicts of interest. |
Some concerns (loss to follow-up, other bias) |
*For further details, see risk of bias table in the appendix
Results
Morbidity (infectious complications) (critical)
Two studies reported the outcome measure morbidity (De Wijkerslooth, 2023; Saar, 2019). Since only two studies reported the outcome measure, the results were not pooled.
De Wijkerslooth (2023) reported morbidity (infectious complications). In total, 51 of the 502 patients (10.2%) who received postoperative antibiotics for two days had an infectious complication, compared with 41 of the 503 patients (8.2%) who received postoperative antibiotics for five days. One of the 51 patients who received postoperative antibiotics for two days and had an infectious complication died. The risk ratio was 1.25 (95% CI 0.84 to 1.84), in favor of the patients who received postoperative antibiotics for five days. The risk difference was 0.02 (95% CI -0.02 to 0.06), in favor of the patients who received postoperative antibiotics for five days. This difference is not considered clinically relevant.
- De Wijkerslooth (2023) reported intra-abdominal abscess. In total, 43 of the 502 patients (8.6%) who received postoperative antibiotics for two days had an intra-abdominal abscess, compared with 36 of the 503 patients (7.2%) who received postoperative antibiotics for five days. The risk ratio was 1.20 (95% CI 0.78 to 1.83), in favor of the patients who received postoperative antibiotics for five days.
- De Wijkerslooth (2023) also reported surgical site infection. In total, 10 of the 502 patients (2%) who received postoperative antibiotics for two days had a surgical site infection, compared with 5 of the 503 patients (1%) who received postoperative antibiotics for five days. The risk ratio was 2.00 (95% CI 0.69 to 5.82), in favor of the patients who received postoperative antibiotics for five days.
Saar (2019) reported morbidity (infectious complications). In total 8 of the 39 patients (20.5%) who received short postoperative antibiotics had an infectious complication, compared with 8 of the 41 patients (19.5%) who received extended postoperative antibiotics. The risk ratio was 1.05 (95% CI 0.44 to 2.53), in favor of the patients who received extended postoperative antibiotics. The risk difference was 0.01 (95% CI -0.17 to 0.19), in favor of the patients who received extended postoperative antibiotics. This difference is not considered clinically relevant.
- Saar (2019) reported organ/space surgical site infection. In total, 3 of the 39 patients (7.7%) who received short postoperative antibiotics had organ/space SSI, compared with 5 of the 41 patients (12.2%) who received extended postoperative antibiotics. The risk ratio was 0.63 (95% CI 0.16 to 2.46), in favor of the patients who received short postoperative antibiotics. The risk difference was -0.05 (95% CI -0.18 to 0.09), in favor of the patients who received short postoperative antibiotics.
- Saar (2019) reported superficial/deep surgical site infection (SSI). In total, 5 of the 39 patients (12.8%) who received short postoperative antibiotics had superficial/deep SSI, compared with 3 of the 41 patients (7.3%) who received extended postoperative antibiotics. The risk ratio was 1.75 (95% CI 0.45 to 6.84), in favor of the patients who received extended postoperative antibiotics. The risk difference was 0.06 (95% CI -0.08 to 0.19), in favor of the patients who received extended postoperative antibiotics.
Mortality (critical)
One study reported the outcome measure mortality (De Wijkerslooth, 2023). In total, 1 of the 502 patients (0.2%) who received postoperative antibiotics for two days died, compared with none of the 503 patients (0%) who received postoperative antibiotics for five days. The risk ratio was 3.01 (95% CI 0.12 to 73.61), in favor of the patients who received postoperative antibiotics for five days. The risk difference was 0.00 (95% CI -0.00 to 0.01). This difference is not considered clinically relevant.
Readmission (important)
Two studies reported the outcome measure hospital readmission (De Wijkerslooth, 2023; Saar, 2019). Since only two studies reported the outcome measure, the results were not pooled.
De Wijkerslooth (2023) reported a total of 58 of the 502 patients (12%) who received postoperative antibiotics for two days were re-admitted to the hospital, compared with 29 of the 503 patients (6%) who received postoperative antibiotics for five days. The risk ratio was 2.00 (95% CI 1.31 to 3.08), in favor of the patients who received postoperative antibiotics for five days. The risk difference was 0.06 (95% CI 0.02 to 0.09), in favor of the patients who received postoperative antibiotics for five days. This difference is not considered clinically relevant.
Saar (2019) reported the outcome measure readmitted patients. In total, 3 of the 39 patients (7.7%) who received short postoperative antibiotics was readmitted, compared with 3 of the 41 patients (7.3%) who received extended postoperative antibiotics. The risk ratio was 1.05 (95% CI 0.23 to 4.90), in favor of the patients who received extended postoperative antibiotics. The risk difference was 0.00 (95% CI -0.11 to 0.12). This difference is not considered clinically relevant.
Costs (important)
De Wijkerslooth (2024) reported the outcome measure costs.
De Wijkerslooth (2024) reported direct health care costs. The mean direct health care costs for the patients who received postoperative antibiotics for two days (n=502) were 3922 euros (SD ± 1912 euros), compared with 4626 euros (SD ± 1619 euros) for the patients who received postoperative antibiotics for five days (n=503). The mean difference was -704 euros (95% CI -923.07 to -484.93), in favor of the patients who received postoperative antibiotics for two days.
De Wijkerslooth (2024) reported overall societal costs. The mean overall societal costs for the patients who received postoperative antibiotics for two days (n=502) were 6146 euros (SD ± 2891 euros), compared with 6771 euros (SD ± 2607 euros) for the patients who received postoperative antibiotics for five days (n=503). The mean difference was -625 euros (95% CI -965.39 to -284.61), in favor of the patients who received postoperative antibiotics for two days.
Length of hospital stay (important)
Two studies reported the outcome measure total length of stay (including readmission days) (De Wijkerslooth, 2023; Saar, 2019). Since only two studies reported the outcome measure, the results were not pooled.
De Wijkerslooth (2023) reported that the patients who received postoperative antibiotics for two days (n=502) had a median total length of stay of 3.0 days (IQR 3.0 to 5.0), compared with a median total length of stay of 5.0 days (IQR 5.0 to 6.0) for the patients who received postoperative antibiotics for five days (n=503). The difference in medians was -2.0 days (95% CI -2.0 to -2.0), in favor of the patients who received postoperative antibiotics for two days. This difference is considered clinically relevant.
De Wijkerslooth (2023) also reported the outcome measure postoperative length of stay. In total, the patients who received postoperative antibiotics for two days (n=502) had a median postoperative length of stay of 3.0 days (IQR 2.0 to 4.0), compared with a median postoperative length of stay of 5.0 days (IQR 5.0 to 6.0) for the patients who received postoperative antibiotics for five days (n=503). The difference in medians was -2.0 days (95% CI -2.0 to 2.0), in favor of the patients who received postoperative antibiotics for two days. This difference is considered clinically relevant.
Saar (2019) reported the outcome measure hospital length of stay. In total, the patients who received short postoperative antibiotics (n=39) had a mean hospital length of stay of 61 hours (SD ±34 hours), compared with a mean hospital length of stay of 81 hours (SD ±40 hours) for the patients who received extended postoperative antibiotics (n=41). The mean difference was -20 hours (95% CI -36.24 to -3.76), in favor of the patients who received short postoperative antibiotics. This difference is not considered clinically relevant.
Antibiotic resistance (important)
None of the included studies reported the outcome measure antibiotic resistance.
Radiological or surgical interventions (important)
Two studies reported the outcome measure radiological or surgical interventions (De Wijkerslooth, 2023; Saar, 2019). Since only two studies reported the outcome measure, the results were not pooled.
De Wijkerslooth (2023) reported any re-intervention. In total, 32 of the 502 patients (6%) who received postoperative antibiotics for two days had any reintervention, compared with 21 of the 503 patients (4%) who received postoperative antibiotics for five days. The risk ratio was 1.53 (95% CI 0.89 to 2.61), in favor of the patients who received postoperative antibiotics for five days. The risk difference was 0.02 (95% CI -0.01 to 0.05), in favor of the patients who received postoperative antibiotics for five days. This difference is not considered clinically relevant.
- De Wijkerslooth (2023) also reported the outcome measure percutaneous drainage separately. In total, 18 of the 502 patients (4%) who received postoperative antibiotics for two days had any reintervention, compared with 13 of the 503 patients (3%) who received postoperative antibiotics for five days. The risk ratio was 1.39 (95% CI 0.69 to 2.80), in favor of the patients who received postoperative antibiotics for five days.
- De Wijkerslooth (2023) also reported the outcome measure reoperation separately. In total, 15 of the 502 patients (3%) who received postoperative antibiotics for two days had a reoperation, compared with 10 of the 503 patients (2%) who received postoperative antibiotics for five days. The risk ratio was 1.50 (95% CI 0.68 to 3.31), in favor of the patients who received postoperative antibiotics for five days.
Saar (2019) reported the outcome measure percutaneous drainage combined with antimicrobial therapy. In total, 2 of the 39 patients (5.1%) who received short postoperative antibiotics underwent percutaneous drainage and antimicrobial therapy, compared with 2 of the 41 patients (4.9%) who received extended postoperative antibiotics. The risk ratio was 1.05 (95% CI 0.16 to 7.10), in favor of the patients who received extended postoperative antibiotics. The risk difference was 0.00 (95% CI -0.09 to 0.10). This difference is not considered clinically relevant.
Any complications (important)
Two studies reported the outcome measure any complications (De Wijkerslooth, 2023; Saar, 2019). Since only two studies reported the outcome measure, the results were not pooled.
De Wijkerslooth (2023) reported any complication (Clavien-Dindo classification 1 to 4a). In total, 125 of the 502 patients (25%) who received postoperative antibiotics for two days suffered from any complications, compared with 104 of the 503 patients (21%) who received postoperative antibiotics for five days. The risk ratio was 1.20 (95% CI 0.96 to 1.51), in favor of the patients who received postoperative antibiotics for five days. The risk difference was 0.04 (95% CI -0.01 to 0.09), in favor of the patients who received postoperative antibiotics for five days. This difference is not considered clinically relevant.
Saar (2019) reported any Clavien-Dindo complication. In total, 7 of the 39 patients (17.9%) who received short postoperative antibiotics had any complication, compared with 12 of the 41 patients (29.3%) who received extended postoperative antibiotics. The risk ratio was 0.61 (95% CI 0.27 to 1.40), in favor of the patients who received short postoperative antibiotics. The risk difference was -0.11 (95% CI -0.30 to 0.07), in favor of the patients who received short postoperative antibiotics. This difference is considered clinically relevant.
A systematic review of the literature was performed to answer the following question(s):
What are (un)favorable effects of short course postoperative antibiotics compared with three or more days of postoperative antibiotics in patients with complex appendicitis who underwent appendectomy?
Table 1. PICO
| Patients | Patients undergoing appendectomy for complex acute appendicitis and who therefore have an indication for postoperative antibiotics |
| Intervention | Shorter than three days of postoperative antibiotics |
| Control | Three days or more of postoperative antibiotics |
| Outcomes | (30 day) morbidity (infectious complications), mortality, readmission, costs, length of hospital stay, antibiotic resistance, radiological or surgical interventions, other complications |
| Other selection criteria | Study design: systematic reviews and randomized controlled trials |
Relevant outcome measures
The guideline panel considered morbidity (infectious complications) and mortality as critical outcome measures for decision making; and readmission, costs, length of hospital stay, antibiotic resistance, radiological or surgical interventions, and other complications as important outcome measures for decision making.
A priori, the guideline panel did not define the outcome measures listed above but used the definitions used in the studies.
The guideline panel defined the following as a minimal clinically (patient) important difference:
- Morbidity (infectious complications): risk difference (RD) 5% - for non-inferiority 7% margin.
- Mortality: RD 1% - for non-inferiority 2% margin.
- Readmission: RD 10% - for non-inferiority 25% margin.
- Length of hospital stay: 1 day.
- Antibiotic resistance: RD 10% - for non-inferiority 15% margin.
- Radiological or surgical interventions: RD 2% - for non-inferiority 5% margin.
- Any complications: RD 10% - for non-inferiority 15% margin.
For costs, the guideline panel did not determine a minimal clinically important difference.
Search and select (Methods)
A systematic literature search was performed by a medical information specialist using the following bibliographic databases: Embase.com and Ovid/Medline. Both databases were searched from 2018 to 21st of November 2024 for systematic reviews and RCTs. Systematic searches were completed using a combination of controlled vocabulary/subject headings (e.g., Emtree-terms, MeSH) wherever they were available and natural language keywords. The overall search strategy was derived from two primary search concepts: (1) appendectomy; (2) postoperative antibiotics. Duplicates were removed using EndNote software. After deduplication a total of 628 records were imported for title/abstract screening. Initially, 21 studies were selected based on title and abstract screening. After reading the full text, eighteen studies were excluded (see the exclusion table under the tab ‘Evidence tabellen’), and three studies were included.
- de Wijkerslooth EML, Boerma EG, van Rossem CC, van Rosmalen J, Baeten CIM, Beverdam FH, Bosmans JWAM, Consten ECJ, Dekker JWT, Emous M, van Geloven AAW, Gijsen AF, Heijnen LA, Jairam AP, Melles DC, van der Ploeg APT, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BPL, van den Boom AL; APPIC Study Group. 2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial. Lancet. 2023 Feb 4;401(10374):366-376. doi: 10.1016/S0140-6736(22)02588-0. Epub 2023 Jan 17. PMID: 36669519.
- de Wijkerslooth EML, Boerma EG, van Rossem CC, Koopmanschap MA, Baeten CIM, Beverdam FH, Bosmans JWAM, Consten ECJ, Dekker JWT, Emous M, van Geloven AAW, Gijsen AF, Heijnen LA, Jairam AP, van der Ploeg APT, Steenvoorde P, Toorenvliet BR, Vermaas M, Wiering B, Wijnhoven BPL, van den Boom AL; APPIC Study Group. Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial. Ann Surg. 2024 May 1;279(5):885-890. doi: 10.1097/SLA.0000000000006089. Epub 2023 Sep 12. PMID: 37698025; PMCID: PMC10997181.
- Saar S, Mihnovitš V, Lustenberger T, Rauk M, Noor EH, Lipping E, Isand KG, Lepp J, Lomp A, Lepner U, Talving P. Twenty-four hour versus extended antibiotic administration after surgery in complicated appendicitis: A randomized controlled trial. J Trauma Acute Care Surg. 2019 Jan;86(1):36-42. doi: 10.1097/TA.0000000000002086. PMID:30308538.
Risk of Bias tables
|
Study reference
(first author, publication year) |
Was the allocation sequence adequately generated?
Definitely yes Probably yes Probably no Definitely no |
Was the allocation adequately concealed?
Definitely yes Probably yes Probably no Definitely no |
Blinding: Was knowledge of the allocated interventions adequately prevented?
Were patients blinded?
Were healthcare providers blinded?
Were data collectors blinded?
Were outcome assessors blinded?
Were data analysts blinded?
Definitely yes Probably yes Probably no Definitely no |
Was loss to follow-up (missing outcome data) infrequent?
Definitely yes Probably yes Probably no Definitely no |
Are reports of the study free of selective outcome reporting?
Definitely yes Probably yes Probably no Definitely no |
Was the study apparently free of other problems that could put it at a risk of bias?
Definitely yes Probably yes Probably no Definitely no |
Overall risk of bias If applicable/necessary, per outcome measure
LOW Some concerns HIGH
|
|
De Wijkerslooth, 2023 (APPIC trial) |
Definitely yes
Reason: Computerised block randomisation was used to allocate patients to intervention or control. |
Probably no
Reason: No information about allocation concealment. |
Definitely no
Reason: Open-label trial (treating physicians and patients were not blinded to treatment allocation). |
Definitely no
Reason: Loss to follow-up was higher than 10% in the intervention group, but lower than 10% in the control group. |
Definitely yes
Reason: All relevant outcome measures were reported. |
Definitely no
Reason: Possible selection bias due to lack of knowledge about non-participation, low, but similar response rate in both groups after 90 days. |
Some concerns |
|
Saar, 2019 |
Definitely yes
Reason: Randomization with a computerized software. |
Probably no
Reason: No information about allocation concealment. |
Definitely no
Reason: Open-label trial. |
No information |
Definitely yes
Reason: All relevant outcome measures were reported. |
Definitely no
Reason: Low number of patients, only adults. |
Some concerns |
Table of excluded studies
|
Reference |
Reason for exclusion |
|
Anandalwar SP, Graham DA, Kashtan MA, Hills-Dunlap JL, Rangel SJ. Influence of Oral Antibiotics Following Discharge on Organ Space Infections in Children With Complicated Appendicitis. Ann Surg. 2021 Apr 1;273(4):821-825. doi: 10.1097/SLA.0000000000003441. PMID: 31274648. |
Not conform PICO: wrong comparison (discharge with vs. without oral antibiotics)
|
|
Arnold MR, Wormer BA, Kao AM, Klima DA, Colavita PD, Cosper GH, Heniford BT, Schulman AM. Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial. Pediatr Surg Int. 2018 Dec;34(12):1257-1268. doi: 10.1007/s00383-018-4343-0. Epub 2018 Sep 14. PMID: 30218170. |
Not conform PICO: wrong comparison (intravenous vs. oral antibiotics)
|
|
Bou Zein Eddine S, Dodgion CM, Qian S, Trevino C, De Moya MA, Yeh DD; EAST Appendicitis Research Group. Complicated Appendicitis: Are Extended Antibiotics Necessary? A Post Hoc Analysis of the EAST Appendicitis "MUSTANG" Study. J Surg Res. 2020 Mar;247:508-513. doi: 10.1016/j.jss.2019.09.054. Epub 2019 Dec 4. PMID: 31812337. |
Post-hoc analysis of an observational study |
|
Chammas M, Pust GD, Hatton G, Pedroza C, Kao L, Rattan R, Namias N, Yeh DD; EAST Appendicitis Study Group. Outcomes of Restricted versus Liberal Post-Operative Antibiotic Use in Patients Undergoing Appendectomy: A DOOR/RADAR Post Hoc Analysis of the EAST Appendicitis MUSTANG Study. Surg Infect (Larchmt). 2022 Jun;23(5):489-494. doi: 10.1089/sur.2021.287. PMID: 35647893. |
Not conform PICO: patients in different categories, wrong outcomes
|
|
Cramm SL, Graham DA, Blakely ML, Kunisaki SM, Chandler NM, Cowles RA, Feng C, He K, Russell RT, Allukian M, Campbell BT, Commander SJ, DeFazio JR, Dukleska K, Echols JC, Esparaz JR, Gerall C, Griggs CL, Hanna DN, Keane OA, Lipskar AM, McLean SE, Pace E, Santore MT, Scholz S, Sferra SR, Tracy ET, Zhang L, Rangel SJ; Eastern Pediatric Surgery Network. Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis. JAMA Surg. 2024 May 1;159(5):511-517. doi: 10.1001/jamasurg.2023.7754. PMID: 38324276; PMCID: PMC10851140. |
Wrong study design: retrospective cohort, not conform PICO: wrong comparison (postoperative antibiotics vs. no postoperative antibiotics)
|
|
Cramm SL, Graham DA, Feng C, Allukian M, Blakely ML, Chandler NM, Cowles RA, Kunisaki SM, Lipskar AM, Russell RT, Santore MT, Campbell BT, Commander SJ, DeFazio JR, Dukleska K, Echols JC, Esparaz JR, Gerall C, Griggs CL, Hanna DN, He K, Keane OA, McLean SE, Pace E, Scholz S, Sferra SR, Tracy ET, Zhang L, Rangel SJ; Eastern Pediatric Surgery Network. Use of Antipseudomonal Antibiotics is Not Associated With Lower Rates of Postoperative Drainage Procedures or More Favorable Culture Profiles in Children With Complicated Appendicitis: Results From a Multicenter Regional Research Consortium. Ann Surg. 2024 Jun 1;279(6):1070-1076. doi: 10.1097/SLA.0000000000006152. Epub 2023 Nov 16. PMID: 37970676. |
Wrong study design: retrospective cohort, not conform PICO: wrong comparison (types of anitbiotics)
|
|
Germer CT, Reibetanz J. Zwei vs. 5 Tage postoperative antibiotische Therapie bei komplizierter Appendizitis: Ergebnisse einer multizentrischen, randomisierten Studie [2 vs. 5 days postoperative antibiotic treatment for complicated appendicitis: results of a multicenter randomized study]. Chirurgie (Heidelb). 2023 Jun;94(6):556-557. German. doi: 10.1007/s00104-023-01885-y. Epub 2023 Apr 27. PMID: 37103572. |
Article in German
|
|
Gordon AJ, Choi JH, Ginsburg H, Kuenzler K, Fisher J, Tomita S. Oral Antibiotics and Abscess Formation After Appendectomy for Perforated Appendicitis in Children. J Surg Res. 2020 Dec;256:56-60. doi: 10.1016/j.jss.2020.05.082. Epub 2020 Jul 16. PMID: 32683057. |
Not conform PICO: wrong comparison (oral antibiotics vs. no antibiotics)
|
|
Keane OA, Motley T, Robinson J, Smith A, Short HL, Santore MT. Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative. J Pediatr Surg. 2024 Jun;59(6):1058-1065. doi: 10.1016/j.jpedsurg.2023.11.001. Epub 2023 Nov 7. PMID: 38030531. |
Wrong study design: pre-post measurements, not conform PICO: wrong comparison (postoperative IV antibiotics +7 days vs. ‘pre-implementation’) |
|
Lee J, Garvey EM, Bundrant N, Hargis-Villanueva A, Kang P, Osuchukwu O, Dekonenko C, Svetanoff WJ, St Peter SD, Padilla B, Ostlie D. IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy. Ann Surg. 2021 Sep 1;274(3):406-410. doi: 10.1097/SLA.0000000000005006. PMID: 34132703. |
Not conform PICO: wrong comparison (monotherapy vs. multi-drug therapy)
|
|
Lipping E, Saar S, Reinsoo A, Bahhir A, Kirsimägi Ü, Lepner U, Talving P. Short Postoperative Intravenous Versus Oral Antibacterial Therapy in Complicated Acute Appendicitis: A Pilot Noninferiority Randomized Trial. Ann Surg. 2024 Feb 1;279(2):191-195. doi: 10.1097/SLA.0000000000006103. Epub 2023 Sep 25. PMID: 37747168. |
Not conform PICO: wrong comparison (IV antibiotics vs. oral antibiotics)
|
|
Liu Q, Hao F, Chen B, Li L, Liu Q, Guo C. Multi-Center Prospective Study of Restrictive Post-Operative Antibiotic Treatment of Children with Complicated Appendicitis. Surg Infect (Larchmt). 2020 Nov;21(9):778-783. doi: 10.1089/sur.2019.293. Epub 2020 Mar 4. PMID: 32150521. |
Not conform PICO: wrong comparison (72h) |
|
Mendoza-Zuchini A, Arce-Polania LC, Pérez-Rivera CJ. Intravenous antibiotic therapy after laparoscopic appendectomy in acute complicated appendicitis: the patient clinical response is the key. Cir Cir. 2023;91(4):479-485. English. doi: 10.24875/CIRU.21000557. PMID: 37677930. |
Wrong study design: observational study, not conform PICO: comparison between methods of administration of antibiotics |
|
Ramson DM, Gao H, Penny-Dimri JC, Liu Z, Khong JN, Caruana CB, Campbell R, Jackson S, Perry LA. Duration of post-operative antibiotic treatment in acute complicated appendicitis: systematic review and meta-analysis. ANZ J Surg. 2021 Jul;91(7-8):1397-1404. doi: 10.1111/ans.16615. Epub 2021 Feb 12. PMID: 33576567. |
Individual studies not conform PICO. In SR: short term vs. extended antibiotics, cut-off not clear. |
|
Sabbagh C, Siembida N, Dupont H, Diouf M, Schmit JL, Boddaert S, Regimbeau JM. The value of post-operative antibiotic therapy after laparoscopic appendectomy for complicated acute appendicitis: a prospective, randomized, double-blinded, placebo-controlled phase III study (ABAP study). Trials. 2020 Jun 1;21(1):451. doi: 10.1186/s13063-020-04411-1. PMID: 32487213; PMCID: PMC7268648. |
Not conform PICO: wrong comparison (no postoperative antibiotics (placebo) vs. postoperative antibiotics for 3 days)
|
|
van den Boom AL, de Wijkerslooth EML, van Rosmalen J, Beverdam FH, Boerma EG, Boermeester MA, Bosmans JWAM, Burghgraef TA, Consten ECJ, Dawson I, Dekker JWT, Emous M, van Geloven AAW, Go PMNYH, Heijnen LA, Huisman SA, Jean Pierre D, de Jonge J, Kloeze JH, Koopmanschap MA, Langeveld HR, Luyer MDP, Melles DC, Mouton JW, van der Ploeg APT, Poelmann FB, Ponten JEH, van Rossem CC, Schreurs WH, Shapiro J, Steenvoorde P, Toorenvliet BR, Verhelst J, Versteegh HP, Wijnen RMH, Wijnhoven BPL. Two versus five days of antibiotics after appendectomy for complex acute appendicitis (APPIC): study protocol for a randomized controlled trial. Trials. 2018 May 2;19(1):263. doi: 10.1186/s13063-018-2629-0. PMID: 29720238; PMCID: PMC5932884. |
Wrong study design: study protocol
|
|
van den Boom AL, de Wijkerslooth EML, Wijnhoven BPL. Systematic Review and Meta-Analysis of Postoperative Antibiotics for Patients with a Complex Appendicitis. Dig Surg. 2020;37(2):101-110. doi: 10.1159/000497482. Epub 2019 Jun 4. PMID: 31163433. |
Only observational studies included in SR |
|
Vanhatalo S, Munukka E, Sippola S, Jalkanen S, Grönroos J, Marttila H, Eerola E, Hurme S, Hakanen AJ, Salminen P; APPAC collaborative study group. Prospective multicentre cohort trial on acute appendicitis and microbiota, aetiology and effects of antimicrobial treatment: study protocol for the MAPPAC (Microbiology APPendicitis ACuta) trial. BMJ Open. 2019 Sep 6;9(9):e031137. doi: 10.1136/bmjopen-2019-031137. PMID: 31494621; PMCID: PMC6731800. |
Not conform PICO: wrong P (uncomplicated and complicated appendicitis), wrong comparison for patients with complicated appendicitis
|
Beoordelingsdatum en geldigheid
Publicatiedatum : 01-06-2026
Beoordeeld op geldigheid : 01-06-2026
Samenstelling werkgroep
Voor het ontwikkelen van de richtlijnmodule is in 2021 een multidisciplinair cluster ingesteld. Het cluster GE-chirurgie bestaat uit meerdere richtlijnen (zie hier de actuele clusterindeling). De stuurgroep bewaakt het proces van modulair onderhoud binnen het cluster. De expertisegroepsleden brengen hun expertise in, indien nodig. De volgende personen uit het cluster zijn betrokken geweest bij de herziening van deze module:
Clusterstuurgroepleden
- Prof. dr. M.A. (Marja) Boermeester, voorzitter, chirurg (NVvH), Amsterdam UMC
- Dr. B.R. (Boudewijn) Toorenvliet, chirurg (NVvH), Ikazia, Rotterdam
- Dr. C.C. (Charles) van Rossem, chirurg (NVvH), Maasstad Ziekenhuis, Rotterdam
- Dr. I. (Ian) Faneyte, Chirurg (NVvH), ZGT, Almelo
- Prof. dr. M.W. (Markus) Hollmann, anesthesioloog (NVA), Amsterdam UMC
- Prof. dr. P.D. (Peter) Siersema, MDL-arts (NVMDL), Erasmus MC, Rotterdam
- Prof. dr. R.G.H. (Regina) Beets-Tan, radioloog (NVvR), Netherlands Cancer Insitute (NKI), Amsterdam
- Mevr. E.C. (Esen) Doganer, beleidsmedewerker, Stichting Kind & Ziekenhuis
Betrokken clusterexpertisegroepleden
- Dr. A.L. (Anne Loes) van den Boom, chirurg (NVvH), Proctos Kliniek, Amsterdam
- Dr. G.I. (Gunnar) Andriesse, arts-microbioloog (NVMM), Certe en Martiniziekenhuis, Groningen
- Dr. S.P. (Suzan) van Mens, arts-microbioloog (NVMM), MUMC+, Maastricht
Met ondersteuning van
- Dr. M.S. (Matthijs) Ruiter, senior adviseur, Kennisinstituut van de Federatie Medisch Specialisten
- Drs. E.R.L. (Evie) Verweg, adviseur, Kennisinstituut van de Federatie Medisch Specialisten
- E. (Esther) van der Bijl, literatuurspecialist, Kennisinstituut van de Federatie Medisch Specialisten
Belangenverklaringen
Een overzicht van de belangen van de clusterleden en het oordeel over het omgaan met eventuele belangen vindt u in onderstaande tabel. De ondertekende belangenverklaringen zijn op te vragen bij het secretariaat van het Kennisinstituut van de Federatie Medisch Specialisten via secretariaat@kennisinstituut.nl.
Gemelde (neven)functies en belangen stuurgroep
|
Naam |
Hoofdfunctie |
Nevenwerkzaamheden |
Persoonlijke financiële belangen |
Persoonlijke relaties |
Extern gefinancierd onderzoek |
Intellectuele belangen |
Overige belangen |
Datum |
Restrictie |
|
Boermeester |
Chirurg |
Medisch Ethische Commissie, Amsterdam UMC, locatie AMC |
Hieronder staan de beroepsmatige relaties met bedrijfsleven vermeld waarbij eventuele financiële belangen via de AMC Research B.V. lopen, dus institutionele en geen persoonlijke gelden zijn: |
Geen |
Institutionele grants van Solventum/3M, Johnson&Johnson
|
Ik maak me sterk voor een 100% evidence-based benadering van maken van aanbevelingen, volledig transparant en reproduceerbaar. Dat is mijn enige belang in deze; geen persoonlijk gewin.
|
Geen |
31-10-2024 |
Geen restricties |
|
Hollmann |
Afdelingshoofd Anesthesiologie Amsterdam UMC locatie AMC en afgevaardigde van NVA
|
Executive Section Editor Pharmacology Anesthesia & Analgesia |
Geen |
Geen |
ZonMw Doelmatigheid (onderzoeken hebben geen betrekking op het onderwerp GE-chirurgie, met name beademingsstudies) |
Geen |
Geen |
19-10-2022 |
Geen restricties |
|
Van Rossem |
Gastro-intestinaal chirurg, Maasstad Ziekenhuis Rotterdam |
Geen |
Geen |
Geen |
Geen |
Geen |
Geen |
06-03-2021 |
Geen restricties |
|
Beets-Tan |
Hoofd Radiologie |
Scientific Director Eur Institute for Biomedical Research (onbetaald). Adviseur Eur Innovation Council |
Geen |
Geen |
Geen |
Geen |
Geen |
09-03-2021 |
Geen restricties |
|
Toorenvliet |
Chirurg, Maatschap Chirurgen en Plastisch Chirurgen Ikazia, Rotterdam |
Chirurg, Heelkunde instituut Nederland (betaald) |
Geen |
Geen |
Geen |
Geen |
Geen |
28-02-2021 |
Geen restricties |
|
Faneyte |
Chirurg Ziekenhuisgroep Twente (ZGT) / Chirurgen Cooperatie Oost-Nederland (ChirCON) |
Voorzitter ChirCON
|
Geen |
Geen |
Geen |
Geen |
Geen |
31-10-2024 |
Geen restricties |
|
Siersema |
Maag-Darm-Leverarts |
Editor in Chief Endoscopie betaald
|
Geen |
Geen |
FujiFilm, Pentax, Sanofi/Regeneron, Magentiq Eye
|
Geen |
Geen |
01-11-2024 |
Geen restricties |
|
Doganer |
Alle projecten van Rowy Uitzinger |
Stichting Kind en Ziekenhuis, Junior Projectmanager/beleidsmedewerker |
Geen |
Geen |
Geen |
Geen |
Geen |
16-06-2022 |
Geen restricties |
Gemelde (neven)functies en belangen expertisegroep
|
Naam |
Hoofdfunctie |
Nevenwerkzaamheden |
Persoonlijke financiële belangen |
Persoonlijke relaties |
Extern gefinancierd onderzoek |
Intellectuele belangen |
Overige belangen |
Datum |
Restrictie |
|
Van den Boom |
Chirurg Proctos Kliniek
|
Geen |
Geen |
Geen |
APPIC trial (onderzoek naar antibiotica na appendectomie), reeds voltooid |
Geen |
Geen |
27-10-2022 |
Restricties t.a.v. besluitvorming rondom postoperatieve antibioticaduur na appendectomie |
|
Andriesse |
Arts-microbioloog bij Certe en Martiniziekenhuis Groningen |
Onderwijsdocent infectiepreventie UMCG (betaald)
|
Geen |
Geen |
Geen |
Geen |
Geen |
22-06-2021 |
Geen restricties |
|
Van Mens |
Arts-microbioloog, MUMC+ |
-Lid werkgroep Richtlijnen NVMM, onbetaald. Inhoudelijk coördineren van bijdrage NVMM aan richtlijnen |
Geen |
Geen |
Geen |
Geen |
Geen |
18-10-2021 |
Geen restricties |
Inbreng patiëntenperspectief
Kwalitatieve raming van mogelijke financiële gevolgen in het kader van de Wkkgz
Bij de richtlijnmodule voerden de clusterleden conform de Wet kwaliteit, klachten en geschillen zorg (Wkkgz) een kwalitatieve raming uit om te beoordelen of de aanbevelingen mogelijk leiden tot substantiële financiële gevolgen. Bij het uitvoeren van deze beoordeling is de richtlijnmodule op verschillende domeinen getoetst (zie het stroomschema bij Werkwijze).
|
Module |
Uitkomst raming |
Toelichting |
|
Postoperatieve antibioticaduur bij acute appendicitis |
Geen financiële gevolgen |
Hoewel uit de toetsing volgt dat de aanbeveling(en) breed toepasbaar zijn (5.000-40.000 patiënten, volgt ook uit de toetsing dat het geen nieuwe manier van zorgverlening of andere organisatie van zorgverlening betreft. Er worden daarom geen financiële gevolgen verwacht. |
Werkwijze
Voor meer details over de gebruikte richtlijnmethodologie verwijzen wij u naar de Werkwijze. Relevante informatie voor de ontwikkeling/herziening van deze richtlijnmodule is hieronder weergegeven.
Zoekverantwoording
Algemene informatie
|
Cluster/richtlijn: GE-chirurgie - Module Postoperatieve antibiotica duur bij acute appendicitis |
|
|
Uitgangsvraag/modules: Wat is de optimale duur van antibiotica na een appendectomie voor een complexe appendicitis? |
|
|
Database(s): Embase.com, Ovid/Medline |
Datum: 21 november 2024 |
|
Periode: vanaf 2018 |
Talen: geen restrictie |
|
Literatuurspecialist: Esther van der Bijl |
Rayyan review: https://new.rayyan.ai/reviews/1235768/overview |
|
BMI-zoekblokken: voor verschillende opdrachten wordt (deels) gebruik gemaakt van de zoekblokken van BMI-Online https://blocks.bmi-online.nl/ Deduplication: voor het ontdubbelen is gebruik gemaakt van http://dedupendnote.nl/ |
|
|
Toelichting: Voor deze vraag is gezocht op de elementen appendectomy EN postoperative antibiotics.
Het sleutelartikel wordt gevonden met deze search. |
|
|
Te gebruiken voor richtlijntekst: A systematic literature search was performed by a medical information specialist using the following bibliographic databases: Embase.com and Ovid/Medline. Both databases were searched from 2018 to 21st November 2024 for systematic reviews and RCTs. Systematic searches were completed using a combination of controlled vocabulary/subject headings (e.g., Emtree-terms, MeSH) wherever they were available and natural language keywords. The overall search strategy was derived from two primary search concepts: (1) appendectomy ; (2) postoperative antibiotics. Duplicates were removed using EndNote software. After deduplication a total of 628 records were imported for title/abstract screening. |
|
Zoekopbrengst - 21 november 2024
|
|
EMBASE |
OVID/MEDLINE |
Ontdubbeld |
|
SR |
176 |
78 |
195 |
|
RCT |
405 |
132 |
433 |
|
Totaal |
581 |
210 |
628* |
*in Rayyan
Zoekstrategie - 21 november 2024
Embase.com
|
No. |
Query |
Results |
|
#1 |
'appendicitis'/exp OR appendic*:ti,ab,kw OR appendix:ti,ab,kw |
76701 |
|
#2 |
'postoperative period'/exp OR 'postoperative care'/exp OR 'postoperative pain'/exp OR postoperati*:ti,ab,kw OR 'post operati*':ti,ab,kw OR postsurg*:ti,ab,kw OR 'post surg*':ti,ab,kw OR 'post remov*':ti,ab,kw OR 'post resecti*':ti,ab,kw OR 'post amputat*':ti,ab,kw |
1596367 |
|
#3 |
#1 AND #2 |
10006 |
|
#4 |
'appendectomy'/exp OR (((appendic* OR appendix) NEAR/3 (remov* OR resecti* OR amputat* OR excision*)):ti,ab,kw) OR appendectom*:ti,ab,kw OR appendicectom*:ti,ab,kw |
33589 |
|
#5 |
#3 OR #4 |
37639 |
|
#6 |
'antiinfective agent'/exp OR 'antibiotic agent'/exp OR 'antibiotic*':ti,ab,kw OR 'anti biotic*':ti,ab,kw |
5420730 |
|
#7 |
#5 AND #6 |
7379 |
|
#8 |
#7 AND [2018-2025]/py NOT ('conference abstract'/it OR 'editorial'/it OR 'letter'/it OR 'note'/it) NOT (('animal'/exp OR 'animal experiment'/exp OR 'animal model'/exp OR 'nonhuman'/exp) NOT 'human'/exp) |
2530 |
|
#9 |
'meta analysis'/exp OR 'meta analysis (topic)'/exp OR metaanaly*:ti,ab OR 'meta analy*':ti,ab OR metanaly*:ti,ab OR 'systematic review'/de OR 'cochrane database of systematic reviews'/jt OR prisma:ti,ab OR prospero:ti,ab OR (((systemati* OR scoping OR umbrella OR 'structured literature') NEAR/3 (review* OR overview*)):ti,ab) OR ((systemic* NEAR/1 review*):ti,ab) OR (((systemati* OR literature OR database* OR 'data base*') NEAR/10 search*):ti,ab) OR (((structured OR comprehensive* OR systemic*) NEAR/3 search*):ti,ab) OR (((literature NEAR/3 review*):ti,ab) AND (search*:ti,ab OR database*:ti,ab OR 'data base*':ti,ab)) OR (('data extraction':ti,ab OR 'data source*':ti,ab) AND 'study selection':ti,ab) OR ('search strategy':ti,ab AND 'selection criteria':ti,ab) OR ('data source*':ti,ab AND 'data synthesis':ti,ab) OR medline:ab OR pubmed:ab OR embase:ab OR cochrane:ab OR (((critical OR rapid) NEAR/2 (review* OR overview* OR synthes*)):ti) OR ((((critical* OR rapid*) NEAR/3 (review* OR overview* OR synthes*)):ab) AND (search*:ab OR database*:ab OR 'data base*':ab)) OR metasynthes*:ti,ab OR 'meta synthes*':ti,ab |
1079182 |
|
#10 |
'clinical trial'/exp OR 'randomization'/exp OR 'single blind procedure'/exp OR 'double blind procedure'/exp OR 'crossover procedure'/exp OR 'placebo'/exp OR 'prospective study'/exp OR rct:ab,ti OR random*:ab,ti OR 'single blind':ab,ti OR 'randomised controlled trial':ab,ti OR 'randomized controlled trial'/exp OR placebo*:ab,ti |
4147130 |
|
#11 |
#8 AND #9 - SR |
176 |
|
#12 |
#8 AND #10 NOT #11 - RCT |
405 |
|
#13 |
#11 OR #12 - Totaal |
581 |
Ovid/Medline
|
# |
Searches |
Results |
|
1 |
exp Appendicitis/ or appendic*.ti,ab,kf. or appendix.ti,ab,kf. |
55311 |
|
2 |
Postoperative Care/ or exp Pain, Postoperative/ or exp Postoperative Period/ or postoperati*.ti,ab,kf. or post operati*.ti,ab,kf. or postsurg*.ti,ab,kf. or post surg*.ti,ab,kf. or post remov*.ti,ab,kf. or post resecti*.ti,ab,kf. or post amputat*.ti,ab,kf. |
913684 |
|
3 |
1 and 2 |
5762 |
|
4 |
exp Appendectomy/ or ((appendic* or appendix) adj3 (remov* or resecti* or amputat* or excision*)).ti,ab,kf. or appendectom*.ti,ab,kf. or appendicectom*.ti,ab,kf. |
19828 |
|
5 |
3 or 4 |
21985 |
|
6 |
exp Anti-Bacterial Agents/ or exp Antibiotic Prophylaxis/ or antibiotic*.ti,ab,kf. or anti biotic*.ti,ab,kf. |
1067753 |
|
7 |
5 and 6 |
2560 |
|
8 |
limit 7 to yr="2018 -Current" |
871 |
|
9 |
8 not (comment/ or editorial/ or letter/) not ((exp animals/ or exp models, animal/) not humans/) |
769 |
|
10 |
meta-analysis/ or meta-analysis as topic/ or (metaanaly* or meta-analy* or metanaly*).ti,ab,kf. or systematic review/ or cochrane.jw. or (prisma or prospero).ti,ab,kf. or ((systemati* or scoping or umbrella or "structured literature") adj3 (review* or overview*)).ti,ab,kf. or (systemic* adj1 review*).ti,ab,kf. or ((systemati* or literature or database* or data-base*) adj10 search*).ti,ab,kf. or ((structured or comprehensive* or systemic*) adj3 search*).ti,ab,kf. or ((literature adj3 review*) and (search* or database* or data-base*)).ti,ab,kf. or (("data extraction" or "data source*") and "study selection").ti,ab,kf. or ("search strategy" and "selection criteria").ti,ab,kf. or ("data source*" and "data synthesis").ti,ab,kf. or (medline or pubmed or embase or cochrane).ab. or ((critical or rapid) adj2 (review* or overview* or synthes*)).ti. or (((critical* or rapid*) adj3 (review* or overview* or synthes*)) and (search* or database* or data-base*)).ab. or (metasynthes* or meta-synthes*).ti,ab,kf. |
791524 |
|
11 |
exp clinical trial/ or randomized controlled trial/ or exp clinical trials as topic/ or randomized controlled trials as topic/ or Random Allocation/ or Double-Blind Method/ or Single-Blind Method/ or (clinical trial, phase i or clinical trial, phase ii or clinical trial, phase iii or clinical trial, phase iv or controlled clinical trial or randomized controlled trial or multicenter study or clinical trial).pt. or random*.ti,ab. or (clinic* adj trial*).tw. or ((singl* or doubl* or treb* or tripl*) adj (blind$3 or mask$3)).tw. or Placebos/ or placebo*.tw. |
2808360 |
|
12 |
9 and 10 - SR |
78 |
|
13 |
(9 and 11) not 12 - RCT |
132 |
|
14 |
12 or 13 - Totaal |
210 |