SESC Annual Meeting Poster Paper

The American Surgeon

Trends in Antibiotic Duration for

2021,  Vol. 87(1) 120­–124
© The Author(s) 2020
Article reuse guidelines:
Complicated Intra-Abdominal sagepub.com/journals-permissions
DOI: 10.1177/0003134820942186
Infections: Adaptation to journals.sagepub.com/home/asu

Current Guidelines

Laura DeCesare, MD1, Thomas Q. Xu, MD1, Constantine Saclarides, MD1,

Julia M. Coughlin, MD1, Sitaram V. Chivukula, MD1, Ashley Woodfin, MD1,
Edie Chan, MD1, Connor Booker, BS1, and Richard Jacobson, MD1

Abstract
Introduction: The 2017 surgical infection society (SIS) guidelines recommend 4 days of antibiotic therapy after
source control for complicated intra-abdominal infections (cIAIs). Inappropriate exposure to antibiotics has a negative
impact on outcomes in individual patients and populations. The goal of this study was to evaluate our institution’s
practice patterns and adherence to current antibiotic guidelines.
Methods: Medical records from 2010 to 2018 for cIAIs were examined. Complicated appendicitis and complicated
diverticulitis cases were included. Exclusion criteria included other etiologies of IAIs, pediatric cases, and cancer
operations.
Results: Fifty-nine complicated appendicitis cases and 96 complicated diverticulitis cases were identified. For all cases,
antibiotic duration prior to publication of the SIS guidelines was significantly longer than post-SIS duration (appendicitis:
12.6 ± 1.1 days pre-SIS [n = 37] vs 9.0 ± 1.1 days post-SIS [n = 22], P = .01; diverticulitis: 15.1 ± 0.8 days pre-SIS [n = 49]
vs 11.2 ± 0.5 post-SIS [n = 47], P = .04). Surgical management (SM) was associated with shorter duration of postsource
control antibiotic exposure compared with percutaneous drainage (PD) for both appendicitis (SM 10.0 ± 1.2 days vs PD
13.4 ± 1.0 days, P = .02) and diverticulitis (SM 12.8 ± 1.5 days vs PD 16.0 ± 1.5, P = .07). Patients with complicated appen-
dicitis received shorter duration of antibiotics when managed by acute care surgeons compared to general surgeons (8.4
± 1.1 vs 11.9 ± 0.8, P = .02).
Conclusion: Despite improvements after the SIS guidelines’ publication, the antibiotic duration is still longer than recom-
mended. Surgical intervention and management by acute care specialists were associated with a shorter duration of antibi-
otic exposure.

Keywords
surgical infections, antibiotic duration, complicated intra-abdominal infections

Introduction In 2015, the Study to Optimize Peritoneal Infection

Complicated intra-abdominal infections (cIAIs) remain
an important cause of hospitalization, morbidity, and
mortality worldwide.1,2 Mainstays of treatment include
appropriate resuscitation, removal of the infected source,
and systemic antimicrobial therapy. Judicious application
of antibiotics is increasingly relevant to surgeons in light
of the emergence of resistant organisms, adverse effects
intrinsic to antibiotic therapy, and more recent data
demonstrating the short-term and long-term dangers of
intestinal dysbiosis.3-5
Therapy (STOP-IT) compared long-course antibiotic
therapy to a fixed short course of antibiotic therapy after
1
Department of Surgery, Rush University Medical Center, Chicago,
IL, USA
Corresponding Author:
Richard Jacobson, MD, Department of Surgery, Rush University
Medical Center, 1750 West Harrison Street, Suite 775, Chicago, IL
60612, USA.
Email: Richard_A_Jacobson@rush.edu
2
DeCesare et al The American Surgeon 00(0)
Table 1. Demographics of Patients Admitted With
Complicated Acute Appendicitis Before and After Publication
of the SIS Guidelines.a
Pre-SIS Post-SIS P value
n 37 22
Demographic
Age 51.3 (3.3) 51.0 (2.8) .93
Male gender 57.10% 50% .79
BMI 31.3 (1.4) 27.8 (1.3) .08
Smoker 18.2% 13.6% 1
Severity
Apache II 8.9 (0.8) 8.6 (0.5) .75
WBC 14.0 (0.9) 14.2 (0.7) .84
Abbreviations: BMI: body mass index (kg/m2); WBC: white blood cell
count (1000 cells/mL); SIS, Surgical Infection Society.
a
Demographics and disease severity were similar for patients
admitted prior to and after publication of the Surgical Infection
Society (SIS) guidelines. Apache II score as calculated based on
admission vital signs and laboratory values.
adequate source-control for cIAI. The study demonstrated
similar outcomes between the 2 groups in rates of surgi-
cal site infection, recurrent intra-abdominal infection,
and death.6 Further work has demonstrated the safety and
efficacy of short-course antibiotic therapy in additional
cohorts, including critically ill patients, patients with sep-
sis on presentation, and patients who have undergone per-
cutaneous drainage.7-9 The 2017 guidelines from the
Surgical Infection Society (SIS), guided by this strong
trial data, recommend 4 days of antibiotic therapy after
source control is attained in cIAI with source control
being defined as the removal of infected fluid and tissue.
Despite the potential risks of undue antibiotic expo-
sure, awareness of and adherence to these recommenda-
tions are variable.10,11 The aim of the present study is to
evaluate 1 health system’s practice patterns and its adap-
tation to the current data and guidelines.
Methods
Following institutional review board approval, a retro-
spective chart review was performed of all patients
admitted to Rush University Medical Center and affiliate
community hospitals with a diagnosis of IAI from January
2010 through December 2018. Admission diagnoses
were identified by international classification of diseases
(ICD)-9 and ICD-10 codes. Inclusion criteria were nar-
rowed to patients with either complicated acute appendi-
citis or complicated acute diverticulitis as these were the
most common diagnoses and determined relevant to a
broad audience of general surgeons. ICD-9 and ICD-10
codes specifying generalized peritonitis, abscess, perfo-
ration, or gangrene were used in the identification of
patients with both appendicitis and diverticulitis. Patients
were excluded if age at admission was less than 18 years,
121
IAI was a secondary diagnosis, infections were uncom-
plicated, or the infection was secondary to a perforated
malignancy. Following identification, a manual chart
review of each case was performed. Basic demographics
included age, gender, body mass index (BMI), and smok-
ing status. Admission date, diagnostic data, procedural
data for source control, and antibiotic duration was also
collected on all included patients by medical record
review.
Comparison of means was carried out using Graphpad
Prism software (GraphPad Software, San Diego, CA,
USA). Standard statistical techniques, either Student’s
t-test or Fisher’s exact test, were performed.
Results
A total of 2295 admissions with the diagnosis of IAI were
identified during the study period; the majority were
uncomplicated infections and ultimately, 155 patients
met our inclusion and exclusion criteria.
Complicated Appendicitis
In patients with complicated appendicitis (n = 59), 37
cases were identified prior to the publication of the guide-
lines (pre-SIS) and 22 took place at least 3 months after
publication (post-SIS). The pre-SIS and post-SIS groups
were demographically similar with no statistical differ-
ence in age, gender, BMI, smoking status, and disease
severity (Table 1). Patient demographics, severity, and
incidence of disease in the current study were comparable
to those published in the STOP-IT trial and others.2,4
On average, the duration of therapy exceeded the SIS
guideline of 4 days following attainment of source con-
trol. Postsource control antibiotic duration was 12.6 ± 1.1
days pre-SIS and 9.0 ± 1.1 days post-SIS (*P = .01
Student’s t-test, Figure 1(A)). To identify factors other
than the time of admission associated with shorter dura-
tion of antibiotic therapy, we next compared patients
admitted at all time points by mode of intervention.
Surgical management (n = 20) was associated with the
shortest duration of therapy after source control (10.0 ±
1.2 days). Patients treated with percutaneous drainage (n
= 19) were exposed to significantly longer durations of
13.4 ± 1.0 days (*P = .02, Figure 1(B)). No difference in
antibiotic duration after source control was observed
between patients undergoing open and laparoscopic sur-
gery (10.0 ± 1.9 vs 10.1 ± 1.5 days, P = .95, Figure 1(C)).
Expectedly, length of stay was significantly shorter in
patients treated laparoscopically (data not shown).
Finally, patients managed by acute care surgeons (n = 16)
compared with general surgeons (n = 43) had signifi-
cantly shorter postsource control antibiotic duration
(8.4 ± 1.1 vs 11.9 ± 0.8, *P = .02, Figure 1(D)).
DeCesare et al
122 The American Surgeon 87(1)3

Figure 1. Antibiotic duration in complicated acute appendicitis. (A) Patients admitted after publication of the guidelines received
shorter courses of antibiotics after source control, in line with but on average still above the SIS guideline of 4 days. (B) Surgically
managed patients had shorter total antibiotic duration than both percutaneously drained patients and those who had no intervention
for source control. (C) Patients managed with both open and laparoscopic surgery had similar total antibiotic duration. (D) Acute
care surgeons, compared with general surgeons prescribed shorter total duration and postsource control duration of therapy.
*P < .05, Student’s t-test.

Table 2. Demographics of Patients Admitted With (Table 2). Forty-six (46.9%) were classified as Hinchey
Complicated Acute Diverticulitis Before and After 1b, 31 (32.3%) were Hinchey 2, and 19 (19.8%) were
Publication of the SIS Guidelines.a Hinchey 3 or 4. The cohort was again comparable to pre-
Pre-SIS Post-SIS P value vious work in demographics and severity of illness.2
Similarly to the complicated appendicitis cohort, the
n 49 47 post-SIS patients were exposed to a significantly shorter
Demographic duration of antibiotic therapy after source control com-
Age 53.3 (2.8) 50.6 (1.9) .42 pared with the pre-SIS group (15.1 ± 0.8 days pre-SIS vs
Male gender 46.9% 31.9% .15 11.2 ± 0.5 post-SIS, *P = .04, Figure 2(A)). Surgical
BMI 33.2 (1.0) 34.0 (1.5) .63 rather than percutaneous intervention was associated
Smoker 10.6% 26.5% .06
with shorter antibiotic duration after source control that
Severity
trended toward but did not reach significance (surgical
Apache II 9.8 (0.5) 8.8 (0.5) .07
WBC 13.0 (0.7) 12.9 (0.6) .85
12.8 ± 1.5 days vs percutaneous 16.0 ± 1.5, P = .07,
Figure 2(B)).
Abbreviations: BMI: body mass index (kg/m2); WBC: white blood cell Due to multiple and sometimes simultaneous medical
count (1000 cells/mL); SIS, Surgical Infection Society. or surgical services involved in the treatment plan for
a
Demographics and disease severity were similar for patients
admitted prior to and after publication of the Surgical Infection complicated diverticulitis, we were unable to evaluate the
Society guidelines. Apache II score as calculated based on admission relationship between subspecialty and antibiotic duration
vital signs and laboratory values. for complicated diverticulitis.

Complicated Diverticulitis Discussion

To assess whether the trends observed in patients with
complicated appendicitis were generalizable to other
cIAI, we reviewed patients with complicated diverticuli-
tis, defined as Hinchey class 1b or above. Patients admit-
ted prior to (n = 49) and after (n = 47) publication of the
SIS guidelines had similar demographics, including age,
gender, BMI, smoking status, and disease severity
The present study evaluated our institution’s practice pat-
terns with regard to the 2017 SIS guidelines for antibiotic
duration following source control in cIAI. We demon-
strate a significant reduction in days of antibiotic duration
for both complicated appendicitis and complicated diver-
ticulitis in patients admitted after the publication of the
guidelines. However, room for improvement remains as
4DeCesare et al The American Surgeon 00(0)
Figure 2. Antibiotic duration in complicated acute
diverticulitis. (A) In a pattern similar to patients with complicated
acute appendicitis, patients admitted after publication of the
guidelines received shorter courses of antibiotics after source
control. (B) On average, patients managed with surgical
intervention had shorter courses of antibiotics postsource
control than those managed percutaneously. This difference
approached but did not reach statistitcal significance. *P < .05,
Student’s t-test.
the mean antibiotic duration after source control was still
greater than the recommended 4-day course.
Antibiotic duration also differed by intervention uti-
lized to achieve source control and surgeon subspecialty.
Surgical intervention was associated with shorter courses
of antibiotics after source control compared with percuta-
neous drainage despite evidence that there is no differ-
ence in outcomes with short antibiotic course after
percutaneous drainage.7 This trend may be attributable to
greater confidence in source control achieved with surgi-
cal management, allowing for direct visualization of the
infected field, rather than percutaneous drainage.
For complicated appendicitis, acute care surgeons uti-
lized shorter antibiotic duration compared with general
surgeons which is similarly reported by Poscillico et al.10
This finding may be due to increased familiarity with sur-
gical infection and critical care literature among acute
care surgeons. As with Poscillico et al, our acute care sur-
geons are also involved in our critical care unit where
antibiotic stewardship may be more closely regulated.
Compared with Poscillico et al, our antibiotic durations
were longer prior to and after publication of the SIS
guidelines. This finding may be due to the fact that their
institution was an enrolling site for the STOP-IT trial, and
institutional awareness of the guidelines was higher.
Limitations of our study include its retrospective and
observational nature. Our study also is a limited represen-
tation of cIAI since only appendicular and diverticular
sources were included. Furthermore, given the multiple
approaches to care, determining exactly when source
123
control was achieved is challenging. Our analysis also did
not include assessment of recommendations by consult-
ing Infectious Disease services.
The safety and efficacy of short-course antibiotics
after source control for cIAI is well established.
Adherence to consensus guidelines for the duration of
therapy is critical for the prevention of undue short-term
and long-term complications of antibiotic therapy and the
development of resistant organisms. Further interven-
tional work, including multidisciplinary, targeted con-
tinuing education modules based on the SIS guidelines to
improve awareness, and adherence, is warranted.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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