key: cord-0999014-56pot8f6
authors: Zvizdic, Zlatan; Vranic, Semir
title: Decreased number of acute appendicitis cases in pediatric population during the COVID-19 pandemic: Any link?
date: 2020-08-21
journal: J Pediatr Surg
DOI: 10.1016/j.jpedsurg.2020.08.016
sha: a5282581a3f700459a04b2cac53b7c23a0c0673c
doc_id: 999014
cord_uid: 56pot8f6

nan

Coronavirus disease-19 (COVID-19) is caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2). COVID-19 outbreak started in December 2019 as an epidemic in Wuhan, China, and has now spread around the world affecting a huge number of patients and causing a substantial burden to our health care systems [1] . The World Health Organization (WHO) recognized early (January 2020) the problem as an "international concern" and on March 11, 2020, as a pandemic.

Non-emergent surgical procedures and outpatient departments/units have been suspended in many countries, particularly in heavily affected regions, so all the hospital resources are readily available for COVID-19 patients [2] . Many institutions have also adopted various alternative diagnostic and therapeutic paths for oncological and surgical patients [3, 4] .

In the US, Centers for Disease Control and the Centers for Medicare & Medicaid Services recommended that health care systems prioritize all urgent visits and consequently delay all elective procedures to mitigate the spread of COVID-19 in health care settings [5] .

However, non-traumatic abdominal surgical emergencies have remained common and likely to continue to appear in the emergency units during the COVID-19 pandemic [6] . Some authors have adopted conservative treatment approaches for COVID-19 positive patients having surgical emergencies such as acute appendicitis (AA), particularly for non-complicated forms [7, 8] reported that 45.5% of children with AA underwent non-operative treatment in one of the COVID-19 epicenters (New York) [11] . Certainly, "antibiotics-first" strategy may be risky and may cause increased rates of complications such as peritonitis at surgery as reported in a systematic review of Podda et al. [12] .

Although the pediatric population appears to be much less affected [13] , the impact and burden on pediatric clinical practice, including pediatric surgery, are substantial. Most pediatric surgery wards have experienced dramatic changes in their daily practice transforming the services into only pediatric surgical urgent-care units [14] . This has led to a marked reduction in number of outpatient visits (reduction from 92% to only 14% in one study) and elective surgeries [14] . myocardial infarction (23% decrease), cerebrovascular stroke (20%), and hyperglycemic crisis (10% decrease) [5] .

The reasons behind the decrease in AA frequency during the COVID-19 pandemic remain unclear. Some authors have proposed that milder forms cay be treated conservatively at home [15] or using antibiotics [9] . Snapiri et al. also reported delays in diagnosing AA in seven pediatric patients having complicated forms of AA [16] . We believe that other factors may contribute to the decrease including various infectious agents (viruses, bacteria, fungi and parasites) whose exposure in the pediatric population and a potential link to AA have been proposed [17, 18] . It is also well-known that some of these pathogens may give specific histomorphological forms of AA [17] . During the lockdown period, it is likely that the exposure to various microbes has been substantially reduced and consequently affected the frequency of AA in pediatric population. Regardless the causes and numbers, all pediatric emergencies, including AA, during the COVID-19 pandemic should be promptly treated as any delay in their diagnosis and treatment may be as big of a threat as the COVID-19 virus itself.

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Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis

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Limiting hospital resources for acute appendicitis in children: Lessons learned from the U.S. epicenter of the COVID-19 pandemic

Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection in Children and Adolescents: A Systematic Review

Considerations for the outpatient practice in pediatric surgery during the novel SARS-CoV-2 pandemic

The Decreasing Incidence of Acute Appendicitis During COVID-19: A Retrospective Multi-centre Study

Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic

Infectious causes of appendicitis

Association of viral infection and appendicitis

The authors declare no conflict of interest.J o u r n a l P r e -p r o o f