Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis

J Surg Res. 2021 Apr:260:141-148. doi: 10.1016/j.jss.2020.11.067. Epub 2020 Dec 16.


Background: Although perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis.

Methods: This is a single-center, retrospective cohort study of children 18 y of age or younger who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared.

Results: Forty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively.

Conclusions: Provider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.

Keywords: Antimicrobial stewardship; Clinical education; Order set; Pediatric appendicitis; Perforated appendicitis; Piperacillin and tazobactam.

MeSH terms

  • Adolescent
  • Anti-Bacterial Agents / therapeutic use*
  • Antimicrobial Stewardship / methods*
  • Antimicrobial Stewardship / statistics & numerical data
  • Appendectomy
  • Appendicitis / drug therapy*
  • Appendicitis / surgery
  • Ceftriaxone / therapeutic use*
  • Child
  • Child, Preschool
  • Combined Modality Therapy
  • Decision Support Systems, Clinical*
  • Drug Administration Schedule
  • Drug Therapy, Combination
  • Electronic Health Records
  • Female
  • Follow-Up Studies
  • Humans
  • Infant
  • Male
  • Metronidazole / therapeutic use*
  • Piperacillin, Tazobactam Drug Combination / therapeutic use*
  • Practice Patterns, Physicians' / statistics & numerical data
  • Retrospective Studies
  • Treatment Outcome


  • Anti-Bacterial Agents
  • Metronidazole
  • Piperacillin, Tazobactam Drug Combination
  • Ceftriaxone