International Journal of Colorectal Disease

https://doi.org/10.1007/s00384-018-2992-z

ORIGINAL ARTICLE

Bacterial culture and antibiotic susceptibility in patients

with acute appendicitis
Dae Woon Song 1 & Byung Kwan Park 1 & Suk Won Suh 1 & Seung Eun Lee 1 & Jong Won Kim 1 & Joong-Min Park 1 &
Hye Ryoun Kim 2 & Mi-Kyung Lee 2 & Yoo Shin Choi 1 & Beom Gyu Kim 1 & Yong Gum Park 1

Accepted: 21 February 2018

# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose Essential treatment of acute appendicitis is surgical resection with the use of appropriate antibiotics. In order to
effectively treat acute appendicitis, it is important to identify the microorganism of acute appendicitis and evaluate the effective
antibiotics.
Methods A total of 694 patients who underwent appendectomy for acute appendicitis and had positive microbial result between
2006 and 2015 were recruited. For microbial assessment, luminal contents of the appendix were swabbed after appendectomy. In
patients with periappendiceal abscess, the specimens were obtained from abscess fluid. The patient characteristics, operative data,
use of antibiotics, the results of microbiology, and postoperative morbidities including surgical site infection (SSI) were retro-
spectively reviewed.
Results The mean age was 38.2 (± 19.8) years, and 422 patients (60.8%) were male. Most of the operations were performed by
conventional laparoscopy (83.1%), followed by single-port laparoscopy (11.8%). The most common microorganism was
Escherichia coli (64.6%), which was susceptible to amoxicillin/clavulanate, ciprofloxacin, most cephalosporins, piperacillin/
tazobactam, and imipenem. The second most common microorganism was Pseudomonas aeruginosa (16.4%), which was
resistant to amoxicillin/clavulanate and cefotaxime. The rate of postoperative morbidity was 8.6%, and the most common type
was superficial SSI (6.2%), followed by ileus (1.2%), gastroenteritis (0.7%), and organ/space SSI (0.3%). P. aeruginosa (odds
ratio = 2.128, 95% confidence interval 1.077–4.206, P = 0.030) was the only significant microorganism associated with SSI
according to multivariate analysis adjusting for other clinical factors.
Conclusions In perforated appendicitis, the use of empirical antibiotics seems to be safe. In some cases of Pseudomonas
infection, adequate antibiotics should be considered.

Keywords Appendicitis . Appendectomy . Microbiology . Adverse effects . Surgical wound infection

Introduction
Acute appendicitis is one of the most common causes of acute
abdomen. For many surgeons, the standard has been resection
alone with single shot antibiotics, and Breal^ antibiotic treat-
ment only in cases of perforation or perityphlitic abscess. In
* Byung Kwan Park
headlet@cau.ac.kr
1
Department of Surgery, Chung-Ang University College of Medicine,
102 Heukseok-Ro, Dongjak-Gu, Seoul 06973, South Korea
2
Department of Laboratory Medicine, Chung-Ang University College
of Medicine, Seoul, South Korea
the past few years, based on trial results, exclusive antibiotic
treatment has become more and more popular. Since
Escherichia coli is known as the most common pathogen in
acute appendicitis, empirical antibiotics have been introduced
against this organism [1]. However, there are reports that
E. coli resistance to quinolones is increasing, and therefore,
microbiology and antibiotic susceptibility studies are essential
when selecting empirical antibiotics [2].
There has been interest in whether uncomplicated acute
appendicitis should be surgically treated. Over the past few
years, there have been trials that suggest that an antibiotics-
first approach without surgery is relatively safe [3, 4]. On the
other hand, a systematic review with meta-analysis showed
that surgical resection remains the treatment of choice for
acute appendicitis, although antibiotic therapy alone may be

considered in selected patients [5]. Furthermore, relatively
broad-spectrum antibiotics, such as ertapenem, and combina-
tions of multiple antibiotics were used in antibiotics-alone-
treated groups in most studies. Although such treatment may
be effective for major microorganisms that cause acute appen-
dicitis, it may lead to multidrug resistance.
Multidrug resistance is a growing problem and is especially
a concern due to worldwide overuse of antibiotics. It is par-
ticularly concerning in connection with resistance to broad-
and extended-spectrum antibiotics for gram-negative bacilli,
such as E. coli, Klebsiella pneumoniae, and Pseudomonas
aeruginosa [6]. Because it has been reported that there is a
greater ratio of quinolone-resistant E. coli in abdominal infec-
tions in Asia compared to other regions, careful selection of
empirical antibiotics is needed [7].
Therefore, we investigated the microbiology of patients
diagnosed with acute appendicitis, who were treated with sur-
gery combined with empirical antibiotics. The purpose of this
study was to identify the common bacteria responsible for
acute appendicitis and appropriate antibiotics for effective
treatment.
Method
Between January 2006 and December 2015, the patients who
underwent laparoscopic appendectomy and were histopatho-
logically diagnosed as having acute appendicitis and had pos-
itive culture result at the Chung-Ang University Hospital were
retrospectively reviewed. Empirical antibiotics were used in
every patient preoperatively, with or without continuation un-
til discharge. When simple, uncomplicated appendicitis was
suspected on physical examination and abdominal/pelvic
computed tomography, a third-generation cephalosporin with
or without metronidazole was given intravenously. With pa-
tients suspected of having more severe infections, broad-
spectrum antibiotics were chosen, including quinolones, pi-
peracillin/tazobactam, or meropenem.
Laparoscopic appendectomy was performed by umbilical
single-port or conventional three-port procedures as docu-
mented in a previous report [8]. The conversion to conven-
tional laparoscopy was defined as any additional port insertion
during single-port laparoscopic appendectomy [9]. The con-
version to open was defined as any additional incision other
than that initially planned for surgery [10].
Luminal contents of the appendix in acute appendicitis
were swabbed after the operation for microbial assessment.
In patients with periappendiceal abscess, the specimens were
obtained from abscess fluid. The specimens were transported
to the laboratory in a Stuart transport medium. Then, the spec-
imens were inoculated on blood agar, chocolate agar, and
MacConkey agar. These samples were cultivated at 37 °C in
a 50-mL/L CO2 aerobic chamber. At the same time, specimens
Int J Colorectal Dis
were inoculated on phenylethanol blood agar and cultivated
for 48 h in a Forma Anaerobic Chamber. Pathogens were
identified and extended-spectrum β-lactamase (ESBL) sus-
ceptibility testing was performed using a Vitek 2 system
(bioMerieux Vitek Inc. Durham, NC, USA) [11].
The clinical characteristics including age, sex, American
Society of Anesthesiologists score, preoperative laboratory
results, and perioperative data were retrospectively reviewed.
Postoperative morbidity was defined as any deviation from
the normal postoperative course until postoperative 30 days
[12]. Patients who had surgical site infections (SSI) were clas-
sified into two groups according to the guideline from the
Centers for Disease Control and Prevention: superficial SSI
and organ/space SSI [13].
Continuous variables were reported as a median and inter-
quartile range (IQR). Noncontinuous variables, including type
of microorganism, were reported as numbers and frequencies.
To identify predictive factors for SSI, differences in clinico-
pathologic characteristics and microorganisms were evaluated
using the χ2 test, Fisher’s exact test, and Student’s t, depend-
ing on the nature of the variables. In multivariable analysis,
binary logistic regression analysis was used for variables with
values of P < 0.05 on univariate analysis. All statistical anal-
yses were performed using SPSS version 20.0 (SPSS, Inc.,
Chicago, IL, USA). This study was reviewed and approved
by the institutional review board committee of the Chung-Ang
University Hospital (IRB No. 1611-006-260).
Results
Of the 1678 patients who underwent laparoscopic appendec-
tomy, 694 (41.4%) patients had positive culture result, 947
(56.4%) had negative result, and the results of 37 (2.2%) pa-
tients were reported as contaminated. Table 1 shows the base-
line characteristics and perioperative data of the total 694 pa-
tients who have positive microbial results. The median age
was 35 (IQR 24–53) years, and most patients were male
(422, 60.8%). In terms of preoperative laboratory results, me-
dian WBC values and C-reactive protein were 12,630 (IQR
10448–14,805)/μL and 28.5 (IQR 13.4–62.3) mg/L.
Conventional laparoscopy (577, 83.1%) was the most com-
monly used operative technique, followed by single-port lap-
aroscopy (82, 11.8%). Most patients underwent appendecto-
my (607, 87.5%). There was no postoperative 30-day mortal-
ity in this study. The most common regimen of empirical
antibiotics was a third-generation cephalosporin and metroni-
dazole (54.7%), followed by cephalosporin only (32.9%),
quinolone and metronidazole (9.4%), quinolone only
(2.1%), piperacillin/tazobactam (0.6%), or meropenem
(0.3%). Postoperative complications occurred in 60 (8.6%)
patients. Among patients with a common postoperative mor-
bidity, 43 (6.2%) had a superficial SSI and 2 (0.3%) had an
Int J Colorectal Dis

Table 1 Baseline patient characteristics and perioperative data Table 2 Distribution of microorganisms

Characteristics Value (N = 694) Microorganism Isolates (N = 694)

Age, median (IQR), years 35 (24–53) Gram-negative

Sex, n (%) Escherichia coli 448 (64.6%)
Male 422 (60.8%) Pseudomonas aeruginosa 114 (16.4%)
Female 272 (39.2%) Klebsiella pneumoniae 37 (5.3%)
Underlying comorbidity, n (%) 108 (15.6%) Citrobacter species 18 (2.6%)
ASA grade, n (%) Enterobacter species 10 (1.4%)
I 486 (70.1%) Serratia marcescens 3 (0.4%)
II 185 (26.7%) Raoultella planticola 3 (0.4%)
III 23 (3.3%) Comamonas testosteroni 2 (0.3%)
WBC, median (IQR), /μL 12,630 (10,448–14,805) Aeromonas species 2 (0.3%)
Hemoglobin, median (IQR), g/dL 13.8 (13.0–14.8) Proteus species 2 (0.3%)
Platelets, median (IQR), × 103/μL 256 (216–322) Acinetobacter baumannii 1 (0.1%)
C-reactive proteina, median (IQR), mg/L 28.5 (13.4–62.3) Yersinia enterocolitica 1 (0.1%)
Complicated appendicitis 494 (71.2%) Morganella morganii 1 (0.1%)
Type of surgery, n (%) Gram-positive
Conventional laparoscopy 577 (83.1%) Enterococcus species 27 (3.9%)
Single-port laparoscopy 82 (11.8%) Streptococcus species 20 (2.9%)
Conversion to conventional laparoscopy 32 (4.6%) Staphylococcus aureus 5 (0.7%)
Conversion to open 3 (0.4%)
Name of surgery, n (%)
Appendectomy 607 (87.5%)
Cecectomy 87 (12.5%)
sulfamethoxazole (susceptibility 10.0, 50.0, 15.7, and 5.8%,
respectively). Enterococcus (27, 3.9%) was the most com-
Postoperative morbidity, n (%) 60 (8.6%)
monly found Gram-positive microorganism, followed by
Superficial surgical site infection 43 (6.2%)
Streptococcus species (20, 2.9%) and Staphylococcus aureus
Ileus 8 (1.2%)
(5, 0.7%). Common Gram-negative species other than E. coli
Gastroenteritis 5 (0.7%)
and P. aeruginosa that were identified were Klebsiella (37,
Organ/space surgical site infection 2 (0.3%)
5.3%), Citrobacter (18, 2.6%), and Enterobacter (10, 1.4%).
Incisional hernia 2 (0.3%)
Table 4 presents the factors associated with SSI after sur-
Postoperative hospital stay, median (IQR), day 4 (3–6)
gery. Young age and P. aeruginosa were associated with SSI
IQR, interquartile range; ASA, American Society of Anesthesiologists; after univariable analysis. On multivariable analysis,
WBC, white blood cell P. aeruginosa was significantly associated with SSI (odds ra-
a
Data of 17 patients were missing tio = 2.128, 95% confidence interval 1.077–4.206, P = 0.030).

organ/space SSI. Postoperative ileus was found in 5 (1.0%)

patients and 4 (0.5%) had undergone conservative manage-
ment for gastroenteritis after surgery. The median postopera-
tive hospital stay was 4 days (IQR 3–6).
There were no patients who had more than one microor-
ganism isolated. Distribution of the microorganism is listed in
Table 2. E. coli (448, 64.6%) was the most common organism
cultured with a luminal swab of the appendix and was suscep-
tible to most antibiotics including piperacillin/tazobactam,
amoxicillin/clavulanate, cefazolin, cefoxitin, cefotaxime, cef-
tazidime, cefepime, ciprofloxacin, levofloxacin, imipenem,
meropenem, and vancomycin (susceptibility 98.9, 89.7,
80.9, 96.1, 83.1, 84.7, 85.9, 76.1, 78.3, 99.8, 96.3, and
100.0%, respectively) (Table 3). P. aeruginosa was the second
most common organism and was resistant to ampicillin,
amoxicillin/clavulanate, cefotaxime, and trimethoprim/
Discussion
Acute appendicitis is a surgical emergency with an annual
incidence reported to be between 8.6 and 11.7 per 10,000
persons [14]. Although the treatment of choice for acute
appendicitis is surgical resection, some studies have shown
that conservative treatment including antibiotics is generally
safe and effective [15–17]. No matter which method a cli-
nician chooses, the appropriate use of antibiotics is inevita-
ble in the treatment of patients with acute appendicitis,
based on accurate bacteriology. The initial antibiotic therapy
is generally empiric, because the patients need immediate
treatment, but the culture results may need up to 24–72 h
to become available.
Table 3 Antibiotic susceptibility

Gram-negative Gram-positive

E. coli (total) E. coli (ESBL) P. aeruginosa K. pneumoniae Citrobacter species Enterobacter Enterococcus Streptococcus S. aureus
(n = 448) (n = 59) (n = 114) (n = 37) (n = 18) species (n = 10) species (n = 27) species (n = 20) (n = 5)

Ampicillin 134/423 (31.7%) 2/59 (3.4%) 10/100 (10.0%) 3/33 (9.1%) 2/10 (20.0%) 1/18 (5.6%) 11/11 (100%) 22/27 (81.5%) 5/5 (100.0%)
Piperacillin 88/187 (47.1%) 21/22 (95.5%) 99/104 (94.6%) 4/21 (19.0%) 5/6 (83.3%) 13/15 (86.7%) 0/0 (0.0%) 1/2 (50.0%) 0/0 (0.0%)
Piperacillin/ 372/376 (98.9%) 50/52 (96.2%) 87/88 (98.9%) 29/30 (96.7%) 8/8 (100%) 13/16 (81.3%) 1/1 (100%) 1/1 (100%) 0/0 (0.0%)
tazobactam
Amoxicillin/ 365/407 (89.7%) 45/58 (77.6%) 5/10 (50.0%) 29/32 (90.6%) 1/9 (11.1%) 3/18 (16.7%) 0/0 (0.0%) 4/5 (80.0%) 0/0 (0.0%)
clavulanate
ESBLa 59/410 (14.4%) NA 0/2 (0.0%) 3/30 (10.0%) 0/0 (0.0%) 0/0 (0.0%) 0/1 (0.0%) 0/0 (0.0%) 0/0 (0.0%)
Cefazolin 224/277 (80.9%) 0/43 (0.0%) 8/8 (100%) 15/15 (100%) 0/4 (0.0%) 1/9 (11.1%) 0/0 (0.0%) 1/1 (100%) 0/0 (0.0%)
Cefoxitin 392/408 (96.1%) 51/59 (86.4%) 7/10 (70.0%) 31/32 (96.9%) 0/9 (0.0%) 5/18 (27.8%) 0/0 (0.0%) 1/1 (100%) 0/0 (0.0%)
Cefotaxime 350/421 (83.1%) 1/59 (1.7%) 16/102 (15.7%) 29/32 (90.6%) 10/10 (100%) 15/18 (83.3%) 9/9 (100%) 2/2 (100%) 0/0 (0.0%)
Ceftazidime 354/418 (84.7%) 2/59 (3.4%) 102/102 (100%) 29/32 (90.6%) 9/9 (100%) 15/18 (83.3%) 0/0 (0.0%) 1/1 (100%) 0/0 (0.0%)
Cefepime 360/419 (85.9%) 2/59 (3.4%) 101/10 (99%) 29/32 (90.6%) 9/9 (100%) 17/18 (94.4%) 0/0 (0.0%) 1/1 (100%) 0/0 (0.0%)
Gentamycin 304/420 (72.4%) 29/59 (49.2%) 94/102 (92.2%) 29/32 (90.6%) 8/9 (88.9%) 17/18 (94.4%) 1/1 (100%) 9/10 (90.0%) 5/5 (100%)
Amikacin 419/419 (100%) 59/59 (100%) 103/103 (100%) 32/32 (100%) 9/9 (100%) 18/18 (100%) 0/0 (0.0%) 1/1 (100%) 0/0 (0.0%)
Tobramycin 139/176 (79.0%) 13/22 (59.1%) 43/44 (97.7%) 18/21 (85.7) 5/6 (83.3%) 15/18 (83.3%) 0/0 (0.0%) 1/1 (100%) 0/0 (0.0%)
Ciprofloxacin 223/293 (76.1%) 15/43 (34.9%) 97/99 (98.0%) 17/17 (100%) 5/5 (100%) 9/9 (100%) 7/7 (100%) 26/26 (100%) 5/5 (100%)
Levofloxacin 112/143 (78.3%) 10/18 (55.6%) 42/44 (95.5%) 16/18 (88.9%) 6/6 (100%) 9/9 (100%) 12/12 (100%) 27/27 (100%) 0/0 (0.0%)
Imipenem 420/421 (99.8%) 59/59 (100%) 104/104 (100%) 33/33 (100%) 9/10 (90.0%) 18/18 (100%) 7/7 (100%) 25/27 (92.6%) 4/4 (100%)
Meropenem 180/187 (96.3%) 20/23 (87.0%) 98/99 (99.0%) 22/22 (100%) 6/6 (100%) 15/15 (100%) 0/0 (0.0%) 2/2 (100%) 0/0 (0.0%)
Aztreonam 356/414 (86.0%) 2/57 (3.5%) 77/103 (74.8%) 29/32 (90.6%) 9/9 (100%) 14/18 (77.8%) 0/0 (0.0%) 1/1 (100%) 0/0 (0.0%)
Trimethoprim/ 250/422 (59.2%) 22/59 (37.3%) 6/104 (5.8%) 28/33 (84.8%) 10/10 (100%) 17/18 (94.4%) 7/7 (100%) 18/26 (69.2%) 5/5 (100%)
sulfamethoxazole
Tetracycline 19/54 (35.2%) 1/6 (16.7%) 2/2 (100%) 3/5 (60.0%) 2/2 (100%) 5/6 (83.3%) 4/12 (33.3%) 8/25 (32.0%) 5/5 (100%)
Vancomycin 3/3 (100.0%) 0/0 (0.0%) 1/1 (100%) 1/1 (100%) 1/1 (100%) 0/0 (0.0%) 12/12 (100%) 23/23 (100%) 5/5 (100%)

ESBL, expended-spectrum beta lactamase; NA, not available

a
Positive results for ESBL
Int J Colorectal Dis
Int J Colorectal Dis

Table 4 Predictive factors associated with SSI

Univariable Multivariable

Patients with SSI Patients without SSI P Odds 95% confidence P

(n = 45) (n = 649) ratio interval

Age, mean ± SD years old 32.5 ± 18.5 38.6 ± 19.8 0.047 0.984 0.968–1.001 0.061
Gender, n (%) 0.841
Male 28 (6.6%) 394 (93.4%)
Female 17 (6.3%) 255 (93.8%)
ASA score ≥ III, n (%) 1 (4.3%) 22 (95.7%) 1.000a
Leukocytosis, n (%) 31 (5.6%) 518 (79.8%) 0.081
Increased CRP, n (%) 37 (6.5%) 528 (83.5%) 0.818
Severity of appendicitis 0.091
Simple 192 (96.0%) 8 (4.0%)
Complicated 457 (92.5%) 37 (7.5%)
Type of surgery, n (%) 1.000a
Laparoscopic 45 (6.5%) 646 (93.5%)
Open 0 (0.0%) 3 (100.0%)
Name of surgery, n (%) 0.219
Appendectomy 42 (6.9%) 565 (93.1%)
Cecectomy 3 (3.4%) 84 (96.6%)
Microorganism, n (%)
Gram-negative 43 (6.7%) 599 (93.3%) 0.567a
E. coli 26 (5.8%) 422 (94.2%) 0.326
P. aeruginosa 13 (11.4%) 101 (88.6%) 0.020 2.128 1.077–4.206 0.030
K. pneumoniae 1 (2.7%) 36 (97.3%) 0.337
Citrobacter species 0 (0.0%) 18 (100.0%) 0.622a
Enterobacter species 0 (0.0%) 10 (100.0%) 1.000a
Serratia 0 (0.0%) 3 (100.0%) 1.000a
Raoultella 0 (0.0%) 3 (100.0%) 1.000a
Comamonas species 2 (100.0%) 0 (0.0%) 0.004a
Aeromonas 0 (0.0%) 2 (100.0%) 1.000a
Proteus mirabilis 0 (0.0%) 2 (100.0%) 1.000a
Acinetobacter baumannii 0 (0.0%) 1 (100.0%) 1.000a
Yersinia 1 (100.0%) 0 (0.0%) 0.065a
Morganella 0 (0.0%) 1 (100.0%) 1.000a
Gram-positive 2 (3.8%) 50 (96.2%)
Enterococcus species 1 (3.7%) 26 (96.3%) 1.000a
Streptococcus species 0 (0.0%) 20 (100.0%) 0.633a
S. aureus 1 (20.0%) 4 (80.0%) 0.286a
Antibiotics, n (%) 0.841
Cephalosporin 16 (7.0%) 213 (93.0%)
Cephalosporin + metronidazole 24 (6.3%) 355 (93.7%)
Quinolone 2 (13.3%) 13 (86.7%)
Quinolone + metronidazole 3 (4.6%) 62 (95.4%)
Meropenem 0 (0.0%) 2 (100.0%)
Piperacillin/tazobactam 0 (0.0%) 4 (100.0%)
Use of metronidazole, n (%) 31 (5.9%) 497 (94.1%) 0.242

SSI, surgical site infection; SD, standard deviation; ASA, American Society of Anesthesiologists; CRP, c-reactive protein
a
Fisher’s exact test

E. coli was the most common pathogen identified in this
study, similar to the findings in previous studies [2, 11, 14, 18,
19]. P. aeruginosa (16.4%) and K. pneumoniae (5.3%) were
followed by E. coli. Some studies reported that P. aeruginosa
is a commonly isolated strain in appendicitis, with an isolation
rate of 19–32%, which was similar in our study [20, 21]. The
isolation rate of K. pneumoniae was reportedly 5–26% [2, 11,
14]. Among Gram-positive bacteria, Streptococcus and
Enterococcus species were the most frequently isolated.
There have been increasing concerns in recent years about
the increasing rate of multidrug-resistant bacteria. Key orga-
nizations, including the Infectious Disease Society of
America, the Centers for Disease Control and Prevention,
and the World Health Organization, have made antibiotic re-
sistance the focus of major reports, conferences, and actions
[22]. This problem has posed a serious challenge for clinicians
worldwide.
In the treatment of acute appendicitis, appropriate antibi-
otics have a major role in patients with infectious complication
after surgery or in those receiving nonsurgical treatment.
Appropriate choice of antibiotics should include agents effec-
tive against facultative and aerobic Gram-negative and anaer-
obic organisms and should be based on knowledge of micro-
bial testing. In a retrospective study on the increasing trend of
resistance to these antibiotics among E. coli isolates in the past
12 years [2], the author advised against the use of a quinolone
as a first-line antibiotic. However, a report in Taiwan proposed
that a quinolone be used to treat community-acquired compli-
cated intraabdominal infections, because E. coli was found to
be 82–85% susceptible to quinolones [23]. Although the rate
of susceptibility to quinolones was just above 70% in this
study, it is not easy to exclude these drugs as first-line therapy,
because they are highly effective against other microorgan-
isms, especially P. aeruginosa. The third-generation cephalo-
sporin that is most commonly used for empirical antibiotic
treatment was effective against most microorganisms includ-
ing E. coli. Cephalosporins also appeared to be appropriate,
according to our results, except against P. aeruginosa.
Piperacillin/tazobactam and carbapenem may be used to treat
P. aeruginosa. However, considering that cephalosporins and
quinolones are equally effective, coverage with these antibi-
otics may be too broad. E. coli also showed high susceptibility
to amikacin, but concerns remain due to nephrotoxicity and
ototoxicity.
In this study, the microbial assessment was conducted by
luminal swab of the appendix according to previous studies [2,
8, 14]. There were also several studies that performed swabs
from other sites, such as abdominal cavity and appendix fossa
[24, 25]. The studies with luminal swab presented higher rate
of positive culture, compared to the studies that performed
swabs from other sites. This might be explained by significant
bacterial translocation that was not identified in noncompli-
cated appendicitis [26]. There are no studies that compared the
Int J Colorectal Dis
difference between different swab sites. Davies HO et al. re-
ported the need of standard protocol of swab in investigating
the microbiology of acute appendicitis [27].
SSI was a common complication after acute appendicitis,
leading to prolonged hospital stay, increased medical cost, and
compromised overall patient outcomes. In this study, the over-
all SSI rate was 6.5%, which was comparable to that in other
studies (4.5–14%) [20, 21, 28]. Moreover, the presence of
P. aeruginosa was a significant predictive factor associated
with SSI. Chen et al. reported that P. aeruginosa was signifi-
cantly associated with SSI after appendectomy, because it was
frequently not covered by prophylactic antibiotics [14]. As in
this study, P. aeruginosa was highly resistant to the third-
generation cephalosporin most commonly used as a prophy-
lactic antibiotic.
The limitation of this study was its retrospective nature.
Although this study was conducted on a large, single-center
retrospective cohort, various prophylactic antibiotics were
used. Moreover, appropriate antibiotic selection for SSI treat-
ment was not evaluated, because the antibiotics tested for
susceptibility were different from those actually used.
Conclusion
E. coli was the most commonly identified microorganism in
patients with acute appendicitis, followed by Pseudomonas.
Generally, the use of empirical antibiotics seems to be safe in
acute appendicitis. In some cases of Pseudomonas infection,
adequate antibiotics should be considered to prevent SSI.
Funding information This research was supported by the Chung-Ang
University Research Grants in 2017.
Compliance with ethical standards
This study was reviewed and approved by the institutional review board
committee of the Chung-Ang University Hospital (IRB No. 1611-006-
260).
Conflict of interest The authors declare that they have no conflicts of
interest.
Ethical approval For this type of study, formal consent is not required.
Informed consent Informed consent was not obtained but the presented
data are anonymized and risk of identification is low.
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