Once-Daily Ceftriaxone Plus Metronidazole Versus Ertapenem and/or Cefoxitin for Pediatric Appendicitis

J Pediatric Infect Dis Soc. 2017 Mar 1;6(1):57-64. doi: 10.1093/jpids/piv082.


Background: Appendicitis is a common surgical emergency in pediatric patients, and broad-spectrum antibiotic therapy is warranted in their care. A simplified once-daily regimen of ceftriaxone and metronidazole (CTX plus MTZ) is cost effective in perforated patients. The goal of this evaluation is to compare a historic regimen of cefoxitin (CFX) in nonperforated cases and ertapenem (ERT) in perforated and abscessed cases with CTX plus MTZ for all cases in terms of efficacy and cost.

Methods: A retrospective review compared outcomes of nonperforated, perforated, and abscessed cases who received the historic regimen or CTX plus MTZ. Length of stay, time to afebrile, time to full feeds, postoperative abscess, and wound infection rates, inpatient readmissions, and antibiotic costs were evaluated.

Results: There were a total of 841 cases reviewed (494 nonperforated, 247 perforated, and 100 abscessed). Overall, the CTX plus MTZ group had a shorter time to afebrile (P < .001). Treatment groups did not differ in length of stay. Postoperative abscess rates were similar between groups (4.1% vs 3.3%, not significant). Other postoperative complications were similar between groups. Total antibiotic cost savings were over $110 000 during the study period (from November 2010 to June 2013).

Conclusions: Both CFX and/or ERT and CTX plus MTZ result in low abscess and complication rates, suggesting both are effective strategies. Treatment with CTX plus MTZ results in a shorter time to afebrile, while also providing significant antibiotic cost savings. Ceftriaxone plus MTZ is a streamlined, cost-effective regimen in the treatment of nonperforated, perforated, and abscessed appendicitis.

Keywords: antibiotics; antimicrobial stewardship; appendicitis; pediatric.

Publication types

  • Case Reports
  • Comparative Study

MeSH terms

  • Abdominal Abscess / drug therapy
  • Abdominal Abscess / economics
  • Adolescent
  • Appendectomy
  • Appendicitis / drug therapy*
  • Appendicitis / economics
  • Cefoxitin / economics
  • Cefoxitin / therapeutic use*
  • Ceftriaxone / economics
  • Ceftriaxone / therapeutic use*
  • Child
  • Child, Preschool
  • Cost Savings / statistics & numerical data
  • Cost-Benefit Analysis / economics
  • Drug Administration Schedule
  • Drug Substitution
  • Drug Therapy, Combination / economics
  • Ertapenem
  • Female
  • Humans
  • Infant
  • Laparoscopy
  • Male
  • Metronidazole / economics
  • Metronidazole / therapeutic use*
  • Retrospective Studies
  • Treatment Outcome
  • Young Adult
  • beta-Lactams / economics
  • beta-Lactams / therapeutic use*


  • beta-Lactams
  • Metronidazole
  • Cefoxitin
  • Ceftriaxone
  • Ertapenem