Ceftriaxone with Metronidazole versus Piperacillin/Tazobactam in the management of complicated appendicitis in children: Results from a multicenter pediatric NSQIP analysis

Published:November 20, 2021DOI:


      • In this study of 654 children with complicated appendicitis, the most common postoperative regimens were ceftriaxone with metronidazole and piperacillin/tazobactam
      • Rates of postoperative organ space infection were similar for patients who received ceftriaxone plus metronidazole and those who received piperacillin/tazobactam
      • Resource utilization was also similar between groups including 30-day postoperative imaging utilization, length of stay, and hospital cost



      Narrow-spectrum antibiotics have been found to be equivalent to anti-Pseudomonal agents in preventing organ space infections (OSI) in children with uncomplicated appendicitis. Comparative effectiveness data for children with complicated appendicitis remains limited. This investigation aimed to compare outcomes between the most common narrow-spectrum regimen (ceftriaxone with metronidazole: CM) and anti-Pseudomonal regimen (piperacillin/tazobactam: PT) used perioperatively in children with complicated appendicitis.


      Multicenter retrospective cohort study using clinical data from the NSQIP-Pediatric Appendectomy Collaborative database merged with antibiotic utilization data from the Pediatric Health Information System database. Mixed-effects multivariate regression was used to compare NSQIP-defined outcomes and resource utilization between treatment groups after adjusting for patient characteristics, disease severity, and clustering of outcomes within hospitals.


      654 patients from 14 hospitals were included, of which 37.9% received CM and 62.1% received PT. Following adjustment, patients in both groups had similar rates of OSI (CM: 13.3% vs. PT: 18.0%, OR 0.88 [95%CI 0.38, 2.03]), drainage procedures (CM: 8.9% vs. PT: 14.9%, OR 0.76 [95%CI 0.30, 1.92]), and postoperative imaging (CM: 19.8% vs. PT: 22.5%, OR 1.17 [95%CI 0.65, 2.12]). Treatment groups also had similar rates of 30-day cumulative post-operative length of stay (CM: 6.1 vs. PT: 6.0 days, RR 1.01 [95%CI 0.81, 1.25]) and hospital cost (CM: $19,235 vs. PT: $20,552, RR 0.92 [95%CI 0.69, 1.23]).


      Rates of organ space infection and resource utilization were similar in children with complicated appendicitis treated with ceftriaxone plus metronidazole and piperacillin/tazobactam.

      Level of Evidence

      Level III: Treatment study - Retrospective comparative study

      Key words


      CDC (Centers for Disease Control and Prevention), CM (Ceftriaxone and metronidazole), ED (Emergency department), ESBL (Extended spectrum beta-lactamase), NSQIP (National Surgery Quality Improvement Program), OSI (Organ space infection), PHIS (Pediatric Health Information System), PLOS (Postoperative length of stay), PT (Piperacillin/tazobactam), SSI (Surgical site infection)
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