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Predictive value of white blood cell count obtained prior to discharge for identifying subsequent organ space infection in children with complicated appendicitis: Results from the Eastern Pediatric Surgery Network
Shannon L. Cramm15, Dionne A. Graham15, Myron Allukian1, Martin L. Blakely2, Brendan Campbell3, Nicole M. Chandler4, Robert A. Cowles6, Jennifer R. DeFazio7, Christina Feng5, Cornelia L. Griggs9, Shaun Kunisaki10, Aaron M. Lipskar11, Robert T. Russell8, Matthew Santore12, Stefan Scholz13, Elisabeth T. Tracy14, Shawn J. Rangel15
1Children's Hospital of Phildelphia, Philadelphia, Pennsylvania, United States, 2Vanderbilt Children's Hospital, Nashville, Tennessee, United States, 3Connecticut Children's Hospital, Hartford, Connecticut, United States, 4Johns Hopkins All Childrens, St. Petersburg, Florida, United States, 5Children's National Hospital, Washington, District of Columbia, United States, 6Yale New Haven Children's Hospital, New Haven, Connecticut, United States, 7New York Presbyterian Morgan Stanely Children's Hospital, New York, New York, United States, 8Children's of Alabama, Birmingham, Alabama, United States, 9Massachusetts General Hospital, Boston, Massachusetts, United States, 10Johns Hopkins Children’s Center, Baltimore, Maryland, United States, 11Cohen Children's Medical Center, New Hyde Park, New York, United States, 12Children's Healthcare of Atlanta, Atlanta, Georgia, United States, 13UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States, 14Duke Children's Hospital and Health Center, Durham, North Carolina, United States, 15Boston Children's Hospital, Boston, Massachusetts, United States

Objective: White blood cell count (WBC) obtained prior to discharge has been used as a strategy to identify children at risk of of post-discharge organ space (OSI) following appendectomy for complicated appendicitis. The objective of this study was to evaluate the predictive value of this practice for identifying patients who develop subsequent post-discharge OSI.

Design: Multicenter cohort study using NSQIP-Pediatric data augmented with pre-discharge WBC data obtained through supplemental chart review.

Setting: 14 children's hospitals participating in the Eastern Pediatric Surgery Network (EPSN).

Patients: Children aged 3-18 with complicated appendicitis who underwent appendectomy from 7/2015 to 6/2020 were included. To minimize inclusion of patients who had a WBC obtained in response to clinical deterioration, patients were excluded if they had a postoperative fever or a surgical site infection diagnosed during their index admission.

Intervention/Exposures: Pre-discharge WBC obtained within one day of discharge during the index admission, categorized by persistent leukocytosis (yes/no), WBC quartile, quartile of proportional change from admission to pre-discharge WBC, and whether pre-discharge WBC was greater/less than admission WBC.

Main Outcome Measure(s): The primary outcome was post-discharge OSI during the 30-day postoperative period. Multivariable regression was used to calculate odds ratios and rates of post-discharge OSI associated with pre-discharge WBC categories, adjusting for disease severity and use of post-discharge antibiotics. Positive/negative predictive values (PPV/NPV) and sensitivity/specificity were calculated based on risk adjusted OSI event rates.

Results: Of 1264 children with complicated appendicitis, 348 (27.5%) had a routine pre-discharge WBC obtained (range by hospital: 0.8 to 100%). Median WBC was similar between children who did and did not develop a post-discharge OSI (9.0 vs. 8.9, p=0.57). Of all WBC comparison categories examined, only pre-discharge WBC greater than admission WBC was associated with increased odds of OSI (Table). Positive predictive value for post-discharge OSI was relatively low and poorly discriminatory across all WBC categories examined, ranging from 1.0% to 10.8% (Table).

Conclusions:
Substantial equipoise exists in the use of pre-discharge WBC in children with complicated appendicitis. The results of this multicenter analysis suggest that routine WBC obtained prior to discharge have limited clinical utility in identifying patients who may benefit from additional antibiotics or diagnostic imaging due to risk of developing subsequent organ space infection.


Table. Predictive utility of pre-discharge white blood cell count (WBC) data on risk of post-discharge organ space infection in children with complicated appendicitis.
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