Effectiveness and Safety of Shortened Postoperative Antibiotic Regimens in Children with Perforated Appendicitis: A Systematic Review and Meta-Analysis

Postoperative antibiotic treatment of varying length is routinely used in perforated appendicitis to reduce the risk of complications. In the pediatric population, outcomes of shortened antibiotic regimens have not been specifically reviewed.Medline, Embase, the Cochrane Library, and CINAHL were searched (October 2023): P, patients: Children with perforated appendicitis; I, intervention and C, comparison: Antibiotic regimen below (I) and above (C) a defined number of days; O, outcomes, focus: Patient risks and benefits. For the main outcome (intra-abdominal abscess), non-inferiority was assessed.Three randomized controlled trials (RCTs; 215 children) and one non-randomized study (288 children) fulfilled the PICO criteria. Regarding intra-abdominal abscess, pooling data from two RCTs (<5 vs. 5 days of intravenous antibiotics; 16 (17%) vs. 15 [15%] events) resulted in a wide 95% confidence interval (risk difference: -8 to 12 percentage points) not meeting the predefined non-inferiority margin of 7.5. One RCT (2 vs. 5 days of intravenous antibiotics) provided data regarding readmissions (9 vs. 7 events) and complications to antibiotic treatment (8 vs. 9 events). Two RCTs (<5 vs. 5 days of intravenous antibiotics) reported significantly shorter length of stay in the intervention group.This systematic review shows neither non-inferiority nor an increased risk of intra-abdominal abscess with a shortened postoperative antibiotic regimen. There may be no difference regarding readmission rates and treatment-related complications. Shorter regimens probably offer the advantage of reduced hospital stay. Due to substantial uncertainties, further RCTs are needed to define the optimal duration of antibiotics in children.