Clinical Paper
Streptococcus anginosus is associated with postoperative intraabdominal collections in appendicitis☆

https://doi.org/10.1016/j.jpedsurg.2017.11.009Get rights and content

Abstract

Aim of study

Streptococcus anginosus group (SA) (formerly Streptococcus milleri) are pathogens recognised to have a high risk of postoperative collection in appendicitis, although little data exist specifically in children. We performed a retrospective review of all microbiological data from appendicectomies to assess whether there was an association in children.

Methods

A retrospective case note review of patients admitted to a paediatric tertiary centre coded for appendicitis from January 2015 to October 2016 was completed. Initial length of stay (LOS), cumulative hospital days, histology, microbiology, and radiology reports were recorded. The postoperative antibiotic regimen was based on surgeon's choice and not standardised.

Main results

231 children were identified, and 18 were excluded. In the remainder, 169 (78.9%) had positive microbiology cultures, and of these 45 were positive for SA (26.6%). There was no significant variation in monthly incidence (P = 0.58). Patients with SA + ve cultures were associated with complicated appendicitis on histology (P = 0.01), longer LOS and cumulative hospital days (P = 0.001), and increased likelihood of developing postoperative collections (P = 0.001). The relative risk of developing a postoperative collection with SA + ve cultures was 2.40. There was no difference in time to presentation, histology, or intervention between SA and non-SA patients who developed collections. All SA cultures were sensitive to penicillin and erythromycin.

Conclusion

SA cultured from intraoperative serial swabs is associated with an increased risk of developing postoperative collection (2.40). Using this information with standardisation of antimicrobial management may reduce the rate of postoperative complications in paediatric appendicitis.

Level of evidence

Level II prognosis study.

Section snippets

Methods

Retrospective case-note review was conducted for all children coded for “appendicitis”, or its synonyms, admitted to our institution between January 2015 and October 2016. Data were collected from review of each patient's discharge summary, microbiology, histology and radiology reports. Data were identified on the length of stay (LOS), cumulative number of hospital days, 30 day readmission rate, intraoperative findings (including histopathology and microbiology swabs of the appendix) and

Results

Between 1st January 2015 and 31st October 2016, 231 children were discharged with the diagnosis of ‘appendicitis’. Eighteen patients were excluded: twelve were treated conservatively with IV antibiotics, three presented with non-specific abdominal pain, two had an interval appendicectomy and one patient had their primary operation at a peripheral centre, leaving 213 to be included in this study.

Mean age at presentation was 9.2 (1.5–16.6) years. An appendix serosal swab was not documented in

Discussion

Our study shows the value of appendix serosal swabs in identifying SA, a species we have found to be associated with longer hospital admissions, more complicated appendix histology and increased development of postoperative abscesses.

The use of intraoperative swabs is a common and longstanding practice in those with complex or perforated appendicitis [3], [4] with the aim of focusing antimicrobial management. Foo et al. [6], however, reported peritoneal microbiology cultures were of little

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    • Cited by (13)

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      Citation Excerpt :

      Streptococcus species were common in our cohort, being isolated in 25 of 40 intra-operative cultures and in four of five patients who ultimately developed a SSI. Finding Streptococcus anginosus at intra-abdominal culture during appendectomy has been shown to confer a 2.4-times relative risk for developing a SSI[31], though its specific mechanism in the development of post-appendectomy SSI is not been completely understood[32]. There is controversy in the use of extended-spectrum antibiotics, specifically, those with anti-pseudomonal coverage, as the empiric choice for CA.

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      The most frequently involved microorganisms are Gram positive, especially the genus Staphylococcus and Streptococcus, although Klebsiella, Eikenella, Salmonella or Acinetobacter have been reported with less frequency [2,3,6]. Streptococcus anginosus group, including closely related species S. constellatus and S. intermedius, are primarily commensals of the mucosa with special ability for developing abscesses [5]. Hematogenous spread is usually the most likely mechanism by which bacteria reach the thyroid gland [3,4], although there are a number of factors that predispose to infection, such as the persistence of congenital remnants basically a pyriform sinus fistula or the presence of thyroglossal duct.

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    Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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