An acute care surgery clinical pathway improves antimicrobial stewardship in patients with acute appendicitis

Author(s):
Garima Thakkar; Celeste Ferguson ; Kevin Kennedy; Nicholas Bennett; Tolulope Oyetunji; Sean Nix ; Andrew Benedict

Background:

Acute care surgery (ACS) encompasses surgical critical care, emergency surgery and the surgical management of trauma. These patients require expertise in appropriate antibiotic selection and comprehensive surgical care in a time sensitive manner.  Following ACS implementation at our institution, we developed a perioperative clinical pathway for acute appendicitis to guide appropriate antibiotic selection and duration.

Hypothesis:

ACS clinical pathway for acute appendicitis improves antimicrobial stewardship.

Methods:

A retrospective study at a tertiary care facility of patients with acute appendicitis who underwent appendectomy.  Demographic data, clinical outcomes and inpatient pharmaceutical data were abstracted from patient medical records.  Patients were classified by pre (January 1, 2016-July 31, 2018) and post-initiation (August 1, 2018-December 31, 2020) of ACS pathway. Primary outcome was perioperative utilization of antibiotic piperacillin-tazobactam. Secondary outcomes included time from computed tomography (CT) scan to antibiotics administered, hospital readmission rates within 30 days of surgery and discharge prescription antibiotic rates in patients with non-perforated appendicitis.  Statistical analysis was performed using SAS with a p-value <0.05 as significant.

Results:

492 patients analyzed with 225 in the pre-clinical pathway and 267 in the post-clinical pathway. Post-operative LOS was significantly decreased in our post clinical pathway cohort (13 hours vs 18 hours, p <0.001) despite treating more patients with perforated appendicitis (29.6% vs. 6.2%, p<.001). 30 day hospital readmission rates were similar between the two cohorts (7.1% vs. 4%, p=.137). A significant decrease in CT to antibiotics administered time (115 vs 126 minutes, p=.008) in our post clinical pathway cohort.  Rates of pre-op (55.4% vs. 60.9%, p<.001) and post-op piperacillin-tazobactam significantly decreased (55% vs. 61.1%, p<.001) following utilization of our clinical pathway. Furthermore, discharge prescription antibiotics in patients with non-perforated appendicitis was reduced following the implementation of our clinical pathway (17% vs. 26.5%, p=.022).

Conclusions:

Our ACS pathway for acute appendicitis resulted in earlier antibiotic administration following diagnosis, decreased use of piperacillin-tazobactam, decreased post-operative LOS, and decreased discharge antibiotic prescriptions for patients without perforation.  Future investigation of the role of an ACS clinical pathway on improving both patient outcomes and antimicrobial stewardship with acute appendicitis is warranted.