IMPPACT Trial: Is it safe to treat perforated appendicitis with monotherapy?

Infographic · Nov 2021 · 1 min read

In brief

Prospective randomized trial of 162 children with perforated appendicitis found monotherapy with piperacillin-tazobactam significantly reduced intraabdominal abscess rates compared to standard two-drug therapy (6.1% vs 23.8%). Monotherapy also decreased CT imaging and emergency visits without increasing complications or antibiotic exposure duration.

Piperacillin-tazobactam monotherapy reduces intraabdominal abscess rate to 6.1% vs 23.8% with combination therapy (P=0.002)
Monotherapy decreases postoperative CT imaging by 50% and emergency department visits by 66% compared to dual-drug regimen
Antibiotic-related complications and treatment duration remain unchanged with monotherapy versus combination therapy
Combination therapy is the strongest predictor of IAA formation (OR 9.21) in multivariate analysis
Strict perforation definition (visible hole or intraperitoneal fecalith) ensures study validity for clinical application

Written by the GCMD Library team from the infographic.

The infographic uses a red and gray color scheme with icons representing the digestive system, medication bottles, syringes, CT scanner, and ambulance. Data is presented in three columns comparing outcomes between treatment arms, with percentages displayed in large text. Gray icons on the left indicate the patient population (under 18 years, perforated appendicitis, n=162).

Abstract

Background:

Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted.

Methods:

A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs.

Results:

One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA.

Conclusions:

In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.

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