Comparison of the efficacy of carbapenems and cephalosporins for postoperative treatment of perforated appendicitis in children

Abstract

BACKGROUND

Pediatric perforated appendicitis (PPA) is a severe acute condition requiring surgical intervention and postoperative antibiotic therapy. Antibiotic selection differs significantly among pediatric centers, and an ideal postoperative anti-infective approach for PPA management has yet to be established.

AIM

To examine the spectrum of pathogenic bacteria in pediatric PPA and to summarize the postoperative experience with carbapenem (CBP) and cephalosporin (CPS) antibiotics.

METHODS

We retrospectively analyzed medical records of 65 children (43 boys, 22 girls; mean age 6.92 ± 3.41 years) with PPA who underwent surgery at our hospital between December 2019 and August 2022. Data were collected in September 2023. Based on postoperative antibiotic selection, patients were divided into CBP (32 cases) and CPS (33 cases) groups. Chi-square and T-tests compared recovery outcomes, while univariate and multivariate regression models identified independent factors affecting postoperative recovery.

RESULTS

There were no significant differences between the two groups in gender, age, weight, height, body mass index, baseline ear temperature, or heart rate (P > 0.05). Escherichia coli (40.00%) and Pseudomonas aeruginosa (24.62%) were the most common pathogens in PPA. Postoperative analysis showed significantly shorter C-reactive protein (CRP) recovery times in the CPS group than in the CBP group [(6.18 ± 1.84) vs (8.12 ± 3.48) days, P = 0.009]. Univariate logistic regression indicated CPS selection (OR = 0.32, 95%CI: 0.10-0.97, P = 0.044) was significantly associated with a higher CRP recovery rate within 7 days. Multivariate analysis confirmed CPS selection (OR = 3.49, 95%CI: 1.19-10.24, P = 0.023) as an independent factor affecting CRP recovery within 7 days postoperatively.

CONCLUSION

The choice of CBP or CPS independently affects CRP recovery within 7 days. CBP offers no advantage over CPS in treating PPA, with CPS also demonstrating favorable clinical outcomes.

Key Words: Children; Perforated appendicitis; Pathogenic bacteria; Carbapenems; Cephalosporins

Core Tip: In the management of pediatric perforated appendicitis (PPA) post-surgery, our retrospective study demonstrates that cephalosporins (CPS) are as effective as carbapenems in achieving favorable clinical outcomes. Notably, CPS use is associated with significantly faster C-reactive protein recovery within seven days, highlighting its potential as a preferred antibiotic choice. These findings support optimizing antibiotic selection to enhance postoperative recovery and mitigate the risks of antibiotic resistance in children treated for PPA.

INTRODUCTION

Acute appendicitis is the most common pediatric surgical emergency globally. Perforated appendicitis (PA) accounts for approximately 30% of pediatric appendicitis cases, with incidence rates being higher in younger children[1,2]. In comparison with non-PA, PA markedly impacts postoperative outcomes, significantly increasing the risk of complications, including abdominal or pelvic abscesses, bowel obstruction, and wound infections, with rates reaching up to 39%[3,4]. Severe PA may result in acute peritonitis, which can lead to dehydration, sepsis, paralytic ileus, or even death[5]. As a critical condition, peritonitis necessitates emergency surgical intervention[6]. Early surgical management is essential for preventing disease progression and mitigating associated risks[7-9].

During the progression of pediatric PA (PPA), bacterial transmigration and invasive infections play pivotal roles in its development and severity. Studies have demonstrated a positive correlation between the severity of clinical manifestations and the detection of bacterial pathogens. As inflammation intensifies, the permeability of the appendiceal wall increases, allowing a greater number of bacterial species to infiltrate, ultimately leading to perforation. This increase in bacterial diversity is associated with a higher risk of complications[10]. Bacteria absorbed through the peritoneum and mesentery can enter systemic circulation, leading to sepsis, which severely compromises patient survival and can be life-threatening. This underscores the importance of analyzing bacterial profiles and antibiotic susceptibility in pediatric cases. Perioperative antibiotic prophylaxis and treatment are crucial in managing appendicitis, significantly improving patient outcomes[11]. Various antibiotic regimens have been evaluated, with differing guidelines addressing their use. Ceftriaxone combined with metronidazole and other anti-infective agents, or broad-spectrum antibiotics with metronidazole, has been widely studied[12,13]. The triple-drug regimen of ampicillin, gentamicin, and clindamycin or metronidazole remains prevalent in hospitals globally[14]. Recent studies have advocated single-agent therapies, such as carbapenems (CBP) or tazobactam/piperacillin, as alternatives to dual or triple regimens for PPA[15,16]. However, resistance to ceftriaxone, particularly by extended-spectrum β-lactamase-producing bacteria and pseudomonas strains, necessitates timely escalation to more effective agents, such as tazobactam/piperacillin, to enhance clinical outcomes and reduce hospitalization duration[17].

Currently, there are no standardized guidelines for antibiotic use in PPA management[18]. Significant uncertainties remain regarding optimal treatment, and the comparative efficacy of CBP and cephalosporins (CPS) have not been thoroughly investigated. Our findings revealed generally low resistance rates to CBP, such as meropenem and imipenem. Appendix pus culture results revealed that not all pathogenic strains are sensitive to CBP. CPSs, being the most commonly used antibiotics for appendicitis, raise the question of whether CBP offers superior efficacy in PPA treatment. This study aimed to address this gap by comparing postoperative outcomes in pediatric PPA cases treated with either CBP or CPS.

MATERIALS AND METHODS

General materials

We retrospectively reviewed the medical records of 65 children (43 boys, 22 girls; mean age: 6.92 ± 3.41 years) diagnosed with PPA and treated with standard laparoscopic appendectomy at our hospital's Pediatric Surgery Department between December 2019 and August 2022. We accessed these data in September 2023 using the hospital's Electronic Data Capture system for research. The antibiotic sensitivity of the pus samples collected from the surface of the appendix was recorded. A retrospective analysis was conducted on pediatric cases of physical activity in our hospital over the past 3 years, focusing on the clinical application of postoperative antibiotics and the duration of clinical follow-up observation (from the initial administration of antibiotics postoperatively until the children were discharged). The clinical outcomes of patients managed with CBP (32 cases) and CPS (33 cases) after PPA surgery were evaluated and compared.

Inclusion and exclusion criteria

Inclusion criteria: (1) The study will include data from November 2019 to August 2022; (2) The patient was diagnosed with PPA during surgery; (3) All patients underwent the traditional three-hole laparoscopic appendectomy and intraoperative procedures were performed according to the description of surgical methods; and (4) All children were treated with antibiotics postoperatively, either CBP or CPS, and were administered a single antibiotic until meeting the cessation criteria.

Exclusion criteria: (1) Cases outside the time frame; (2) Non-PA diagnosed during surgery; (3) Patients underwent either non-three-hole laparoscopic appendectomy or laparoscopic conversion to laparotomy; (4) Patients did not receive intraoperative abdominal irrigation or abdominal drainage tube; and (5) Postoperative antibiotics other than CBP or CPS were selected, or combination of antibiotics, or change of antibiotics.

Surgical methods

Three hole laparoscopic appendectomy was performed. The patients were placed in a Trendelenburg position angled 15° toward the surgeon. A 30-degree 5-mm camera was inserted through the umbilical trocar, and a 5-mm trocar was inserted through the McGilliard point and the suprapubic region. Throughout the surgical procedure, the appendix was excised entirely, the abdominal cavity was irrigated with normal saline, and drainage tubes were inserted into each abdominal cavity.

Strategy for antibiotic selection

For the CPS group, if antimicrobial susceptibility testing confirmed sensitivity or yielded inconclusive results for the initial CPS, the original regimen was maintained. If resistance was detected, a sensitive CPS alternative was selected. The initial CPS therapy was continued when the susceptibility results were negative but the clinical symptoms and laboratory findings showed improvement. Importantly, even in cases of resistance to CPS, symptomatic improvement was observed during treatment. Postoperative antibiotic discontinuation was based on the following criteria: (1) Tolerance of a normal diet with spontaneous bowel movements; (2) Absence of fever (ear temperature < 37.3 °C) for more than 48 hours; (3) Full resolution of abdominal symptoms, such as pain, bloating, diarrhea, or constipation; (4) No evidence of infection at the surgical site; and (5) C-reactive protein (CRP) levels < 10 mg/L (Figure 1).

Figure 1 Postoperative antibiotic management flowchart for pediatric perforated appendicitis in our center. ¹The detected strains were insensitive to other cephalosporin (CPSs), and the initial CPS was maintained until clinical symptoms and laboratory indicators improved. CPS: Cephalosporin; PA: Perforated appendicitis.

Statistical analysis

Data analysis was conducted using GraphPad Prism 9.0. Continuous data with normal distribution were expressed as mean ± SD and analyzed using the t test. Categorical data were expressed as frequency (proportion) and analyzed using the χ² test. Univariate and multivariate analyses were performed using the binary/multinomial logistic regression model to evaluate the impact of perioperative factors on postoperative recovery. The OR and 95%CI were calculated to assess the impact of each factor on prognosis. All statistical tests were two-sided, with P < 0.05 considered statistically significant.

RESULTS

General characteristics

There were no statistically significant differences in gender, age, weight, height, body mass index, ear temperature, or heart rate at baseline between the two groups (P > 0.05), confirming the comparability of the data (Table 1).

Table 1 Preoperative baseline data characteristics of the two groups of patients, mean ± SD.

Characteristics	CBP	CPS	T value or χ2	P value
Number of patients (n)	32	33	-	-
Gender (n, male:female)	23:9	20:13	0.921	0.337
Age (year)	6.94 ± 3.48	6.86 ± 3.20	0.095	0.924
Weight (kg)	29.63 ± 15.64	24.26 ± 9.21	1.694	0.095
Height (m)	1.21 ± 0.23	1.25 ± 0.23	0.747	0.457
BMI (n)	18.48 ± 2.72	17.33 ± 2.77	1.829	0.071
Ear temperature (℃)1	37.92 ± 0.73	37.60 ± 0.716	1.735	0.088
Heart rate (bpm)	113.03 ± 16.53	111.12 ± 15.32	0.483	0.630

¹Temperature measured on admission.

CBP: Carbapenem; CPS: Cephalosporin; BMI: Body mass index.

Analysis of the situation regarding pathogenic bacterial infections

A total of 65 samples were tested, all yielding positive bacterial cultures. Among these, 26 cases (40.00%) involved Escherichia coli (E. coli), 16 cases (24.62%) Pseudomonas aeruginosa (P. aeruginosa), 11 cases (16.92%) were co-infected with both bacteria, and 12 cases (18.46%) were caused by other strains, including Klebsiella pneumoniae, Proteus vulgaris, Streptococcus constellatus, Comamonas testosteroni, Citrobacter freundii, Enterococcus avium, and Streptococcus anginosus. The predominant pathogens in PPA were E. coli and P. aeruginosa. Both strains exhibited 0.00% resistance to ceftazidime, piperacillin-tazobactam, and CBP, whereas P. aeruginosa also showed 0.00% resistance to aztreonam and ceftazidime. Mixed infections involving two strains were labeled as "Combine" in the table, whereas other infections were categorized as "Others". Both categories displayed 0.00% resistance to amikacin, piperacillin-tazobactam, and CBP. For "Others", the highest resistance rate was observed with cefazolin at 75.00% (Table 2).

Table 2 Antimicrobial resistance profiles of the two major strains of bacteria, n (%).

Antimicrobial resistance	Pathogenic bacterial species
	E. coli (n = 26)	P. aeruginosa (n = 16)	Combine (n = 11)	Others (n = 12)
Amikacin	1 (3.70)	0 (0.00)	0 (0.00)	0 (0.00)
Amoxicillin/clavulanic acid potassium	8 (30.77)	6 (37.50)	3 (27.27)	4 (33.33)
Aztreonam	4 (15.38)	0 (0.00)	0 (0.00)	1 (8.33)
Gentamicin	4 (15.38)	4 (25.00)	3 (27.27)	3 (25.00)
Ceftazidime	0 (0.00)	0 (0.00)	0 (0.00)	1 (8.33)
Cefuroxime	12 (46.15)	6 (37.50)	4 (36.36)	6 (50.00)
Cefazolin	15 (57.69)	9 (56.25)	5 (45.45)	9 (75.00)
SMZ-TMP	11 (42.31)	8 (50.00)	5 (45.45)	6 (50.00)
Piperacillin tazobactam	0 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)
Meropenem	0 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)
Imipenem	0 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)
Levofloxacin	3 (11.54)	2 (12.50)	2 (18.18)	0 (0.00)

E. coli: Escherichia coli; P. aeruginosa: Pseudomonas aeruginosa.

Impact of antibiotics on postoperative recovery

Postoperative characteristics revealed significantly shorter CRP recovery times in the CPS group compared with the CBP group [CPS: (6.18 ± 1.84) days vs CBP: (8.12 ± 3.48) days, P = 0.009]. However, the comparison of antibiotic effects on postoperative recovery showed no statistically significant differences between the two groups in gastrointestinal function (GF) recovery time, hospital stay length, or complications such as bowel obstruction, ascites, abdominal abscess, and wound infections (all P > 0.05) (Table 3).

Table 3 Comparison of the effect of antibiotics on the postoperative recovery of children in two groups, n (%).

Project	CBP	CPS	Z value or χ2	P value
CRP recovery time (days)	8.12 ± 3.48	6.18 ± 1.84	2.59	0.009
GF recovery time (hours)	38.84 ± 23.37	35.08 ± 20.92	0.61	0.542
Hospital stay length (days)	8.63 ± 3.01	8.97 ± 2.80	0.94	0.344
Complications			3.41	0.065
No	25 (78.12)	31 (93.94)
Yes	7 (21.88)	2 (6.06)
Bowel obstruction			1.13	0.287
No	29 (90.62)	32 (96.97)
Yes	3 (9.38)	1 (3.03)
Ascites			3.24	0.072
No	29 (90.62)	33 (100.00)
Yes	3 (9.38)	0 (0.00)
Abdominal abscess			1.05	0.306
No	31(96.87)	33 (100.00)
Yes	1 (3.13)	0 (0.00)
Wound infections			0.98	0.321
No	32 (100.00)	32 (96.97)
Yes	0 (0.00)	1 (3.03)

CRP: C-reactive protein; GF: Gastrointestinal function; CBP: Carbapenem; CPS: Cephalosporin.

Univariate analysis of binary logistic regression model to evaluate the impact of perioperative factors on postoperative recovery

Univariate analysis of baseline characteristics and C-reactive protein recovery rate within 7 days postoperatively: Among baseline characteristics, the proportion of CPS antibiotic selection (OR = 0.32, 95%CI: 0.10-0.97, P = 0.044) was significantly associated with a higher CRP recovery rate within 7 days postoperatively (P < 0.05) (Table 4).

Table 4 Univariate analysis of binary logistic regression model for baseline characteristics and C-reactive protein recovery rate within 7 days postoperatively, n (%).

Project	n = 65	OR	95%CI	P value
Gender
Female	22 (33.85)	1.00	Refer
Male	43 (66.15)	1.10	0.35-3.46	0.878
Age (year)
≤ 5	24 (36.92)	1.00	Refer
> 5	41 (63.08)	0.56	0.19-1.68	0.300
Ear temperature (℃)
< 37.3	20 (30.77)	1.00	Refer
≥ 37.3	45 (69.23)	0.61	0.19-1.99	0.415
Antibiotic selection
CBP	32 (49.23)	1.00	Refer
CPS	35 (53.85)	3.92	1.32-11.62	0.014
Complications
No	56 (86.15)	1.00	Refer	-
Yes	9 (13.85)	0.82	0.18-3.71	0.797

CBP: Carbapenem; CPS: Cephalosporin.

Univariate analysis of baseline characteristics and gastrointestinal function recovery rate within 48 hours postoperatively: Among baseline characteristics, including gender, age, Ear temperature, antibiotic selection, and complications, none were significantly associated with a higher GF recovery rate within 48h postoperatively (all P > 0.05) (Table 5).

Table 5 Univariate analysis of binary logistic regression model for baseline characteristics and gastrointestinal function recovery rate within 48 hours postoperatively, n (%).

Project	n = 65	OR	95%CI	P value
Gender
Female	22 (33.85)	1.00	Refer
Male	43 (66.15)	1.61	0.48-5.46	0.441
Age (year)
≤ 5	24 (36.92)	1.00	Refer
> 5	41 (63.08)	1.16	0.36-3.72	0.803
Ear temperature (℃)
< 37.3	20 (30.77)	1.00	Refer
≥ 37.3	45 (69.23)	0.32	0.08-1.35	0.122
Antibiotic selection
CBP	32 (49.23)	1.00	Refer
CPS	35 (53.85)	2.69	0.82-8.81	0.103
Complications
No	56 (86.15)	1.00	Refer	-
Yes	9 (13.85)	0.819	0.17-4.01	0.806

CBP: Carbapenem; CPS: Cephalosporin.

Multivariate analysis of perioperative characteristics and C-reactive protein recovery rate within 7 days postoperatively

Variables with P < 0.05 from the multivariate analysis of antibiotic selection was included in the multinomial logistic regression model. The results showed that antibiotic selection (OR = 3.49, 95%CI: 1.19-10.24, P = 0.023) was an independent factor affecting the CRP recovery rate within 7 days postoperatively (Table 6).

Table 6 Multivariate analysis of multinomial logistic regression model for perioperative characteristics and C-reactive protein recovery rate within 7 days postoperatively, n (%).

Project	n = 65	OR	95%CI	P value
Antibiotic selection
CBP	32 (49.23)	1.00	Refer
CPS	35 (53.85)	3.49	1.19-10.24	0.023
Pathogenic bacteria species
E. coli	26 (40.00)	1.00	Refer
P. aeruginosa	16 (24.62)	0.84	0.20-3.56	0.818
Combine	11 (16.92)	0.76	0.15-3.89	0.739
Others	12 (20.00)	0.79	0.14-4.37	0.785

CBP: Carbapenem; CPS: Cephalosporin; E. coli: Escherichia coli; P. aeruginosa: Pseudomonas aeruginosa.

DISCUSSION

Newman et al[19] documented appendicitis perforation rates ranging from 20% to 76% across 30 pediatric hospitals in the United States, with an average of 36%. Acute PA is a frequent complication in pediatric appendicitis owing to anatomical and physiological factors, such as the free cecum, A thin appendix wall abundant in lymphoid tissue, common retinal dysplasia, and the extensive surface area of the peritoneal cavity. These factors increase the risk of PA, resulting in celiac inflammation, challenges in infection control, and elevated complication rates[20]. In the present study, Frequent postoperative complications included bowel obstruction [CBP: 3 cases (9.38%) vs CPS: 1 case (3.03%); P = 0.287], ascites [CBP: 3 cases (9.38%) vs CPS: 0 cases (0.00%); P = 0.072], abdominal abscess [CBP: 1 case (3.13%) vs CPS: 0 cases (0.00%); P = 0.306], and wound infections [CBP: 1 case (3.13%) vs CPS: 0 cases (0.00%); P = 0.321]. The rates of postoperative complications did not differ between the CBP and CPS groups. Some researchers have proposed omitting intraoperative pus cultures and antimicrobial susceptibility testing[21]. However, we argue that peritoneal pus culture remains cost-effective, convenient, and clinically valuable. Schülin et al[22] demonstrated considerable diversity in the appendix microbiome of acute pediatric appendicitis exhibits considerable diversity, with notable variations in microbial composition within the appendix lumen based on inflammation severity. These variations may contribute to the proliferation of pathogenic bacteria described in the appendix. In our study, pus cultures revealed common infections with E. coli and P. , with 26 cases (40.00%) involving E. coli, 16 cases (24.62%) involving P. aeruginosa, 11 cases (16.92%) involving both bacteria, and 12 cases (18.46%) caused by other strains, including Klebsiella pneumonia, Proteus vulgaris, Streptococcus constellatus, Comamonas testosteroni, Citrobacter freundii, Enterococcus avium and Streptococcus anginosus.

Antibiotics are crucial for the management of PPA. Tsai et al[23] highlighted that surgery is the optimal early treatment for PPA, thereby reducing both the antibiotic duration and hospital stay. According to Turel et al[24], selecting antibiotics based on pathogen test results is essential for guiding clinical PPA treatment. In our study, postoperative CRP recovery times were notably shorter in the CPS group than in the CBP group [CPS: (6.18 ± 1.84) days vs CBP: (8.12 ± 3.48) days, P = 0.009]. However, standardized protocols for postoperative antibiotic use in pediatric appendicitis remain unavailable[25]. The misuse of antibiotics has intensified the emergence of resistant bacterial strains, thereby diminishing the efficacy of conventional treatments. Plattner et al[26] concluded that in non-critical pediatric cases, broad-spectrum antibiotics or prolonged post-discharge antibiotic use did not significantly enhance clinical outcomes. Thus, the identification of the most effective antibiotic regimens is an ongoing research.

E. coli and P. aeruginosa exhibited high sensitivity to third-generation CPSs, such as ceftazidime and ceftizoxime, making these antibiotics suitable empirical agents for treating PPA while awaiting susceptibility results. Our findings indicate that certain bacteria are sensitive to CBP, but resistant to CPS. Although current guidelines exclude CBP as a first-line treatment for PPA, our results suggest its potential utility. Some studies have proposed management strategies for CBP use[27]. However, The dependence on broad-spectrum antibiotics and the use of restricted-grade antibiotics heightens the risk of colonization and infection by multidrug-resistant organisms[28]. Notably, excessive empirical use of meropenem has been linked to the emergence of CBP-resistant gram-negative bacteria[29], necessitating cautious use. In our study, pathogens were largely sensitive to CPSs, penicillins, and aminoglycosides, making these drugs preferred for empirical therapy. Nonetheless, resistance of E. coli to penicillins, such as amoxicillin-clavulanic acid, has been associated with higher postoperative complication rates[30].

Aminoglycosides exhibit efficacy against both bacilli and P. aeruginosa, their nephrotoxic[31] and ototoxic[32] effects pose risks, particularly in pediatric patients. As a result, we prioritized CPSs as the primary antibiotics in our treatment protocol and research focus, avoiding aminoglycosides due to their potential adverse effects.

White blood cells (WBC) are key inflammatory cells, and their exudate plays a crucial role in the inflammatory response. However, WBC counts can fluctuate within a specific range depending on the time and functional state of the body. Additionally, some laboratory indicators may vary due to these factors, WBC are central to inflammatory processes, and their presence in exudates serves as a hallmark of inflammation. However, WBC counts fluctuate within a specific range depending on temporal, physiological, and functional states. Factors such as age, emotional stress, and pain can significantly influence WBC counts. Notably, in certain cases of severe infections, WBC counts may decrease rather than increase, limiting their specificity in assessing the severity of acute appendicitis[33]. Consequently, WBC counts were excluded from the withdrawal criteria. In contrast, CRP is widely recognized as one of the most sensitive biomarkers of acute-phase reactions in humans. CRP levels increase swiftly during acute inflammatory events and are largely unaffected by physiological factors or antibiotic therapy, showing a strong positive correlation with the severity of infection. Previous studies have reported that elevated CRP levels are significantly associated with the severity of appendicitis in pediatric patients, particularly in complicated PPA[34]. To eliminate potential bias in the definition of PA[35], we adopted a clear intraoperative definition and confined the study population to a narrowly defined group.

PPA predisposes patients, particularly children with compromised immune barrier function, to systemic infections, such as bacteremia and sepsis, necessitating combination antibiotic therapies or escalated treatment regimens. To minimize confounding variables, the study was restricted to pediatric patients without immunodeficiencies or hemodynamic instability. This approach reduced the influence of factors such as WBC count, peritoneal contamination, and operative duration, thereby enhancing the objectivity and precision of the study conclusions. Consequently, CRP was included as a key parameter for comparative evaluation. Our findings revealed that CRP recovery times were significantly shorter in the CPS group than in the CBP group [CPS: (6.18 ± 1.84) days vs CBP: (8.12 ± 3.48) days, P = 0.009]. The choice of CPS or CBP antibiotics was an independent determinant of CRP recovery rates within 7 days postoperatively (OR = 3.49, 95%CI: 1.19-10.24, P = 0.023). Furthermore, CPS antibiotic use (OR = 0.32, 95%CI: 0.10-0.97, P = 0.044) was significantly associated with improved CRP recovery rates within the same timeframe. It has been proposed that levels of vascular endothelial growth factor and nitric oxide are elevated during inflammatory states in animals, including cases of sepsis. CPS has been demonstrated to significantly reduce both parameters, which are strongly associated with the inflammatory response. Furthermore, the reduction in these biomarkers is linked to a decrease in CRP levels. This association may partially explain the mechanism by which CPS promotes a more rapid recovery in CRP levels[36]. These findings underscore the therapeutic advantage of CPS over CBP in this context.

The limitations of this study are that the retrospective case data were confined to a single-center analysis. Furthermore, children who experienced secondary complications after discharge may have been excluded from the statistical analysis, potentially leading to unreported data. Another limitation of this study was the classification of treatment groups based solely on the initial antibiotic regimen administered within the first 24 hours after admission. Postoperative modifications to antibiotic therapy might have influenced the outcomes. Nonetheless, given that such changes were infrequent, we adopted this classification approach, as we hypothesized that the ultimate antibiotic regimen would exert a more significant effect on postoperative PPA outcomes while minimizing potential sources of bias.

Future research directions include: (1) Investigating the mechanisms by which various antibiotics influence PPA prognosis, with a focus on basic research to uncover their molecular biological pathways; (2) Designing personalized perioperative antibiotic protocols to minimize adverse outcomes while maintaining effective control of inflammation; (3) Extending follow-up durations to evaluate the influence of perioperative factors on long-term complications associated with PPA; and (4) Undertaking multicenter, prospective studies to increase sample sizes and gather more comprehensive clinical data, particularly regarding perioperative antibiotic administration.

CONCLUSION

In summary, this retrospective analysis of clinical data from 65 patients with PPA identified the choice between CBP and CPS antibiotics as an independent determinant of CRP recovery rates within the first 7 days after surgery. Notably, CPS demonstrated comparable, if not superior, efficacy to CBP in managing PPA, achieving similarly favorable clinical outcomes.