Lack of standardisation
A comment in an earlier issue of the Journal of the Norwegian Medical Association (Tidsskrift for Den norske legeforening) about optimal antibiotic prophylaxis for appendectomy did not specify the recommended antibiotic prophylaxis for children (2). The current practice is to use a different antibiotic regimen for children than for adults. The Norwegian Directorate of Health's national clinical guidelines for antibiotics in hospitals recommend antibiotic prophylaxis with 400 mg doxycycline and 1 g metronidazole as the first-line treatment in gastrointestinal surgery, including acute appendicitis in adults (3). However, the guidelines do not cover children. In practice, metronidazole is used in combination with either gentamicin, cefotaxime, cefuroxime or cefazolin for children.
The comment on antibiotic prophylaxis and interval appendectomy emphasises the importance of routinely administering doxycycline and metronidazole immediately following the decision to carry out an appendectomy, unless a more serious condition is suspected that requires a therapeutic antibiotic regimen (4). There are good reasons for using doxycycline and metronidazole to also treat children, including their long half-life and favourable resistance and ecological profile compared with cephalosporin regimens.
There are good reasons for using doxycycline and metronidazole to also treat children, including their long half-life and favourable resistance and ecological profile
Traditionally, doxycycline has not been recommended for children under the age of 8 due to the risk of tooth staining. However, recent evidence demonstrates that short-course treatment does not cause tooth staining and that doxycycline can be used in children of all ages when deemed appropriate (1, 4, 5). For example, American health authorities recommend doxycycline for children of all ages with neuroborreliosis and rickettsiosis (up to 21 days of treatment) (5).
On this basis, we recommend using a combination of doxycycline and metronidazole as perioperative antibiotic prophylaxis in gastrointestinal surgery, including acute appendicitis, also for children of all ages.