Post-discharge oral antibiotics show no benefit for pediatric appendicitis

Acute appendicitis is one of the most common surgical emergencies among children, and complicated acute appendicitis (CAA), including perforated or gangrenous disease, carries a higher risk of infection and longer hospitalization. While intravenous antibiotics during hospitalization are standard practice, the role of oral home antibiotics (OHA) after discharge remains controversial. Many hospitals continue oral home antibiotics (OHA) to prevent delayed infection, but this practice varies across surgeons and institutions. At the same time, unnecessary antibiotic exposure can cause adverse reactions, disrupt the gut microbiota, increase the risk of Clostridioides difficile infection, and contribute to antimicrobial resistance. These concerns have intensified calls for stronger evidence regarding the real-world value of post-discharge antibiotics in children with CAA.

Researchers from the Pediatric Surgery Department, Complejo Asistencial Universitario de León, Spain, and the Pediatric Surgery Department, Hospital Universitario Niño Jesús, Madrid, Spain, published their findings online in World Journal of Pediatrics on January 27, 2026 (DOI: 10.1007/s12519-025-01008-z). The study assessed whether OHA after discharge reduces infectious complications or readmissions compared with no-home antibiotics (NHA) in children treated surgically for CAA.

The investigators searched PubMed, Web of Science, Scopus, Ovid, and Cochrane Central from database inception to March 2025, and the review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO). Fourteen observational studies involving 26,174 pediatric patients were included. Importantly, no randomized controlled trials (RCTs) were identified, underscoring the limited strength of the currently available evidence. Random-effects meta-analyses were conducted for intra-abdominal abscesses (IAAs), surgical site infections (SSIs), OSIs, and hospital readmissions.

Across the pooled analyses, OHA did not significantly lower the risk of IAAs, OSIs, or readmissions. The pooled risk ratio was 1.23 for IAAs, 1.19 for OSIs, and 1.07 for readmissions, with all 95% confidence intervals crossing the null thresholds. Although SSIs appeared lower in the OHA group in the overall analysis, this signal disappeared in sensitivity analyses limited to studies with crude patient-level exposure data, suggesting that protocol differences and confounding may have shaped the result. In exposure-restricted analysis, children discharged without antibiotics showed a modestly lower readmission risk, raising a possible signal of harm from routine OHA.

The authors said these findings should not be read as a call to abandon clinical judgment, but as evidence that automatic antibiotic continuation after discharge needs stronger justification. They said the review shows a consistent gap between common practice and proven benefit: children with CAA are often sent home with antibiotics because the disease feels risky, yet the available evidence does not show a reliable reduction in key complications. They also emphasized that the certainty of evidence remains very low, mainly because all included studies were observational and vulnerable to confounding by indication.

This study supports a more selective and evidence-based approach to post-discharge care for children with CAA. For hospitals, the results may inform antibiotic stewardship programs, discharge pathways, and shared decision-making with families. Reducing unnecessary OHA could lower medication burden, limit adverse events, and help address antimicrobial resistance without compromising recovery, if paired with clear discharge criteria and follow-up plans. However, the authors stress that high-quality multicenter RCTs are urgently needed to determine which children, if any, truly benefit from antibiotics after discharge. Until then, routine OHA use after surgery for pediatric CAA is not supported by the current evidence.