Delaying Appendectomy Does Not Lead to Higher Rates of Surgical Site Infections: A Multi-institutional Analysis of Children With Appendicitis

Objectives: To investigate the association between time to appendectomy and the risk of surgical site infections (SSIs) in children with appendicitis across multiple NSQIP-Pediatrics institutions. Background: Several recently published single institution retrospective studies have reported conflicting relationships between delaying appendectomy and the risk of increasing surgical site infections (SSI) in both children and adults. This study combines data from NSQIP-Pediatrics with institutional data to perform a multi-institutional analysis to examine the effects of delaying appendectomy on surgical site infections. Methods: Data from NSQIP-Pediatrics between January 2010 and June 2012 for cases of appendectomy for appendicitis at 6 institutions (preoperative characteristics, time of operation, and postoperative occurrences) were combined with data from medical record review (length of symptoms; times of initial presentation, emergency department (ED) triage, and admission; and diagnosis as simple appendicitis (SA, acute) or complicated appendicitis (CA, gangrenous/ruptured)). Cochran-Armitage tests for trend and multivariable logistic regression models were used to evaluate associations between time to appendectomy and SSI. Results: Of the 1338 patients included, 70% had SA and 30% had CA. Postoperative SSIs were more common in CA (5.7% vs 1.2%, P < 0.001). SSI rates did not differ significantly across hospitals (P = 0.17). Compared with patients who did not develop an SSI, patients who developed an SSI had similar times between ED triage and appendectomy (median (interquartile range) 11.5 hours (6.4–14.7) versus 9.7 hours (5.8–15.6, P = 0.36), and similar times from admission to appendectomy (5.5 hours (1.9–10.2) versus 4.3 hours (1.4–9.9), P = 0.36). Independent risk factors for SSI were CA (Odds Ratio (95% CI): 3.46 (1.48–8.10), P = 0.004), longer symptom duration (OR for a 10-hour increase: 1.05 (1.01–1.10), P = 0.02), and presence of sepsis/septic shock (2.70 (1.17–6.28), P = 0.02). Conclusions: A 16-hour delay from ED presentation or a 12-hour delay from hospital admission to appendectomy was not associated with an increased risk for SSI.