Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

J Pediatr Surg. 2008 Jun;43(6):981-5. doi: 10.1016/j.jpedsurg.2008.02.018.


Introduction: Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens.

Methods: After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82.

Results: One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group.

Conclusions: Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

Publication types

  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Abscess / diagnosis
  • Abscess / drug therapy*
  • Abscess / surgery
  • Administration, Oral
  • Adolescent
  • Antibiotic Prophylaxis
  • Appendectomy / economics*
  • Appendectomy / methods
  • Appendicitis / diagnosis
  • Appendicitis / drug therapy*
  • Appendicitis / surgery
  • Ceftriaxone / administration & dosage*
  • Ceftriaxone / economics
  • Child
  • Cost-Benefit Analysis
  • Dose-Response Relationship, Drug
  • Drug Administration Schedule
  • Drug Therapy, Combination
  • Female
  • Follow-Up Studies
  • Gentamicins / administration & dosage*
  • Gentamicins / economics
  • Hospital Costs
  • Humans
  • Infusions, Intravenous
  • Male
  • Metronidazole / administration & dosage*
  • Metronidazole / economics
  • Multivariate Analysis
  • Probability
  • Prospective Studies
  • Treatment Outcome


  • Gentamicins
  • Metronidazole
  • Ceftriaxone