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    3. Volume 21
    4. Optimization of antibiotic use after appendectomy for uncomplicated appendicitis in adults: further evidence supporting restriction of postoperative antibiotic therapy
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GMS Hygiene and Infection Control

Deutsche Gesellschaft für Allgemeine und Krankenhaus-Hygiene (DGKH)

ISSN 2196-5226


Letter to the Editor

Optimization of antibiotic use after appendectomy for uncomplicated appendicitis in adults: further evidence supporting restriction of postoperative antibiotic therapy

 María Mellado-García 1
Hajar Dahmouni-Dahmouni 1
Jesús Sandoval-Marín 1
Miguel González-Valverde 2

1 General Surgery Resident. Hospital General Universitario Reina Sofía, Murcia, Spain
2 General and Digestive Surgery Service. Hospital General Universitario Reina Sofía, Murcia, Spain



Letter to the editor

Dear editor,

We read with great interest the recent article by Beltz et al. [1], in which the authors described the positive impact of implementing a standardized protocol based on antimicrobial stewardship principles on postoperative antibiotic management in pediatric appendicitis. They demonstrated significant improvements in the quality of antibiotic therapy, including reduced postoperative antibiotic exposure without an increase in complications.

We would like to provide additional evidence supporting this strategy in the setting of emergency surgery in adult patients.

At our secondary-level hospital, we conducted a retrospective pre–post quality improvement study to evaluate the effect of a low-cost educational intervention on postoperative antibiotic prescribing after appendectomy for uncomplicated acute appendicitis. The intervention, carried out between October and December 2025 as part of our Antimicrobial Stewardship Program (ASP), consisted of educational sessions for the surgical team, dissemination of updated recommendations, and reminder posters placed in surgical and inpatient areas.

During the pre-intervention period (January–September 2025), 25 of 139 patients with uncomplicated appendicitis (17.9%) received postoperative antibiotic therapy despite adequate surgical source control. Following the intervention, only 4 of 39 patients (10.3%) received postoperative antibiotics during the post-intervention period (January–March 2026), representing a relative reduction of 42.9%, without an increase in postoperative complications.

Our results were similar to those reported by Beltz et al. [1], despite involving an adult population and a different hospital setting. In both studies, a substantial proportion of postoperative antibiotic exposure after appendectomy appeared to remain avoidable and was mainly related to persistent clinical variability and routine antibiotic use rather than evidence-based indications.

Current guidelines do not recommend postoperative antibiotic therapy for uncomplicated appendicitis after adequate appendectomy and proper source control [2], [3], [4]. Nevertheless, this practice remains common in daily clinical care. Such unnecessary exposure is not harmless and contributes to bacterial resistance, adverse drug reactions, Clostridioides difficile infection, prolonged hospital stay, and increased healthcare costs. Recent recommendations from the Surgical Infection Society and the WSES guidelines have emphasized the importance of introducing antimicrobial stewardship strategies in emergency surgery [3], [4].

In our experience, relatively simple educational interventions achieved clinically relevant improvements without requiring complex structural changes or additional economic resources. Therefore, the implementation of standardized protocols and continued educational reinforcement may help improve adherence to evidence-based recommendations.

Recent large-scale analyses of pediatric appendicitis care have shown a progressive reduction in unnecessary postoperative antibiotic use over recent years [5]. This likely reflects greater incorporation of antimicrobial stewardship programs into surgical practice. However, considerable variability between centers still persists, suggesting substantial room for improvement.

We agree with Beltz et al. [1] that antimicrobial stewardship principles should be systematically integrated into appendicitis management pathways. Prospective multicenter studies, in both pediatric and adult populations, would be valuable to confirm these findings and support broader implementation of these strategies in routine clinical practice.

Notes

Authors’ ORCIDs

Funding

This research has not received funding from public sector agencies, commercial entities, or non-profit organisations

Competing interests

The authors declare that they have no competing interests.

AI usage statement

Artificial intelligence was used exclusively for linguistic enhancement. All scientific content and writing are the sole work of the author.

References

[1] Beltz S, Fischer S, Huenger F, Vahdad R, Kalhoff H, Leutner A. Better care for children with appendicitis: implementation of antibiotic stewardship optimizes postoperative therapy. GMS Hyg Infect Control. 2025;20:Doc17. DOI: 10.3205/dgkh000535
[2] Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15;50(2):133-64. DOI: 10.1086/649554
[3] Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020 Apr 15;15(1):27. DOI: 10.1186/s13017-020-00306-3
[4] Huston JM, Barie PS, Dellinger EP, Forrester JD, Duane TM, Tessier JM, Sawyer RG, Cainzos MA, Rasa K, Chipman JG, Kao LS, Pieracci FM, Colling KP, Heffernan DS, Lester J; Therapeutics and Guidelines Committee. The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update. Surg Infect (Larchmt). 2024 Aug;25(6):419-35. DOI: 10.1089/sur.2024.137
[5] Lin AM, Asti L, Carroll M, Minneci PC. Adoption and implementation of evidence-based practices into pediatric appendectomy care. J Pediatr Surg. 2026 Jan;61(1):162719. DOI: 10.1016/j.jpedsurg.2025.162719