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Pediatr Infect Dis J. 2019 Oct;38(10):1054-1060. doi: 10.1097/INF.0000000000002434.

Microbiota of Children With Complex Appendicitis: Different Composition and Diversity of The Microbiota in Children With Complex Compared With Simple Appendicitis.

Author information

From the Department of Paediatric Surgery, Emma Children's Hospital.
Department of Medical Microbiology and Infection Control.
Department of Paediatric Gastroenterology.
Paediatric Clinical Research Office.
Department of Paediatrics, Emma Children's Hospital.
Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, The Netherlands.
Department of Experimental Immunology, Amsterdam University Medical Centre, Amsterdam, The Netherlands.
Heinrich-Pette-Institute, Hamburg, Germany.
inbiome b.v., Amsterdam, The Netherlands.



Two types of appendicitis are hypothesized, simple and complex, with potential different treatment strategies. To improve differentiation, underlying pathogeneses need to be further unraveled.


To determine if the microbial composition in the appendix differs between children with simple and complex appendicitis.


Two-center, prospective cohort study including 40 children (0-17 years old) undergoing appendectomy for suspected appendicitis. Appendix tissue was used for IS-pro analysis to identify bacterial species by their length of 16S-23S rDNA interspacer (IS) region. Cluster analysis, based on IS-profiles, and correspondence with type of appendicitis, using Fisher exact test, was performed. Simple and complex appendicitis were compared regarding bacterial presence, intensity and diversity, using Fisher exact test and Mann-Whitney U test, respectively.


Appendicitis was confirmed in 36 of 40 patients (16 simple, 20 complex). Cluster analysis identified 2 clusters, encompassing 34 patients. Distribution of simple and complex appendicitis was 12 (80%) and 3 (20%) versus 3 (16%) and 16 (84%) patients for clusters 1 and 2, respectively (P < 0.001). Complex appendicitis was on phylum level characterized by an increased intensity (Bacteroidetes P = 0.001, Firmicutes, Actinobacteria, Fusobacteria and Verrucomicrobia (FAFV) P = 0.005 and Proteobacteria P < 0.001) and diversity (Bacteroidetes P = 0.001 and Proteobacteria P = 0.016) and an increased abundance of 5 species (Alistipes finegoldii P = 0.009, Bacteroides fragilis P = 0.002, Escherichia coli P = 0.014, Parvimonas micra P = 0.022 and Sutterella spp P = 0.026).


The microbial composition of the appendix differs between children with simple and complex appendicitis, regarding both composition and diversity. Future research should focus on the role of these bacteria in the pathogenesis of both types and its implications for preoperative diagnostics.

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