Send Them Home! No Increase in Cost for Children With Perforated Appendicitis Who Develop Organ-Space Infection

Authors:
Erin Morris, Jeannette Joly, Krysta Sutyak, Natalie Drucker, KuoJen Tsao

Body of Abstract:
Background: Intra-abdominal abscess (IAA) is a common and costly complication following perforated appendicitis in children. To improve quality of care and promote antibiotic stewardship, our institution implemented several practice changes aimed at reducing hospital length of stay (LOS), including minimizing unnecessary postoperative imaging, basing discharge decisions on clinical recovery rather than laboratory normalization, and adopting a short-course antibiotic protocol. To better understand the economic impact of these early discharge strategies, this study evaluates the clinical outcomes and 30-day hospital costs among children who develop organ-space surgical site infection (OS-SSI) after perforated appendicitis

Methods: We retrospectively reviewed pediatric patients with complicated appendicitis (6/2021–6/2025). Demographics, hospital course, and 30-day outcomes were collected. Total hospital-perspective cost was obtained from the cost accounting system and inflated to 2025 USD using the Consumer Price Index for medical care. Univariate and multivariable generalized linear models with a gamma distribution and log link were used

Results: In total, 612 patients were included (222 (36.3%) female; median age 10 years [IQR 7-13]; median BMI 20 [IQR 16.9-24.8). Median index LOS was 3 days (IQR 3-5), and the overall readmission rate was 8.5% (n=52). OS-SSI occurred in 18.1% (n=111) of patients, including 65 (10.6%) diagnosed during the index hospitalization and 46 (7.5%) after discharge. Age (p=0.56) and sex (p=0.87) did not differ between groups, though BMI was higher among those diagnosed during the index admission (24.1 ± 10.2) compared with those readmitted (17.4 ± 5.4, p=0.02). Index LOS was significantly longer for in-hospital OS-SSI (11 ± 3.7 days) than for patients later readmitted with OS-SSI (3 ± 1.7 days, p<0.001). Percutaneous drainage was performed in 13.2% of patients, including 80% (52/65) of index cases and 63% (29/46) of readmission cases (p=0.048). The mean 30-day cost for all patients was $28,602 ± 14,378, while those with OS-SSI averaged $50,092 ± 19,822. Mean cost was $53,612 ± 21,292 for OS-SSI diagnosed during the index stay and $45,120 ± 16,509 for those diagnosed on readmission. After adjustment for age, sex, and BMI, readmission OS-SSI was associated with 0.84-fold lower cost (95% CI 0.72–0.97, p=0.02) compared with OS-SSI identified during the index hospitalization Conclusion: Post-operative OS-SSI dramatically increases overall costs following perforated appendicitis in children. Patients discharged earlier who may be readmitted with OS-SSI incurred lower adjusted 30-day hospital costs compared with those diagnosed during the index admission. These findings suggest that interventions to promote early discharge of patients can be cost-effective, despite potential for readmission. Continued efforts are needed to reduce the incidence of initial OS-SSI.