What are the appropriate antibiotics for a suspected incisional infection post appendectomy?

From the Guidelines

For a suspected incisional infection post appendectomy, empiric antibiotic therapy with cefazolin 1-2g IV every 8 hours or cefuroxime 1.5g IV every 8 hours is recommended, with a treatment duration of 3-5 days, as supported by the most recent and highest quality study 1.

Key Considerations

• The choice of antibiotic should target common skin flora and enteric organisms, as suggested by 1.
• For patients with penicillin allergy, clindamycin 600-900mg IV every 8 hours is an appropriate alternative, as indicated by 1.
• If MRSA is a concern, adding vancomycin 15-20mg/kg IV every 12 hours may be necessary, as noted in the example answer.
• In cases where gram-negative coverage is needed, consider adding gentamicin 5-7mg/kg IV daily or ciprofloxacin 400mg IV every 12 hours, as suggested by the example answer.
• For broader coverage, piperacillin-tazobactam 3.375g IV every 6 hours or meropenem 1g IV every 8 hours may be used, as indicated by the example answer.

Treatment Duration and Wound Care

• Treatment duration typically ranges from 3-5 days, depending on infection severity, as recommended by 1 and 1.
• Transition to oral antibiotics once clinical improvement occurs is essential, as noted in the example answer.
• Alongside antibiotics, wound care including drainage of any collections, debridement of necrotic tissue, and regular dressing changes is crucial, as suggested by the example answer.

Antibiotic Selection and Patient-Specific Factors

• Antibiotic selection should ultimately be guided by culture results when available, local resistance patterns, and patient-specific factors such as allergies and renal function, as indicated by 1 and the example answer.
• Discontinuation of antimicrobial treatment should be based on clinical and laboratory criteria, such as fever and leucocytosis, as suggested by 1.

From the FDA Drug Label

CEFOTAN (Cefotetan for Injection, USP) is indicated for the therapeutic treatment of the following infections when caused by susceptible strains of the designated organisms:

• Skin and Skin Structure Infections due to Staphylococcus aureus (methicillin-susceptible), Staphylococcus epidermidis (methicillin susceptible), Streptococcus pyogenes, Streptococcus species, Escherichia coli, Klebsiella pneumoniae, Peptococcus niger*, Peptostreptococcus species

The appropriate antibiotics for a suspected incisional infection post appendectomy include Cefotetan.

• The recommended dosage is 2 grams every 12 hours intravenously for severe skin and skin structure infections 2.
• Cefoxitin may also be considered as an alternative option for the treatment of skin and skin structure infections, including those caused by susceptible strains of Staphylococcus aureus, Streptococcus species, and Escherichia coli 3.
• It is essential to note that the choice of antibiotic should be based on the severity of the infection, the susceptibility of the causative organism, and the patient's condition.
• In cases where the causative organism is unknown, empiric therapy with a broad-spectrum antibiotic such as Cefotetan or Cefoxitin may be initiated, and then adjusted based on culture and susceptibility results 2.

From the Research

Appropriate Antibiotics for Suspected Incisional Infection Post Appendectomy

• The choice of antibiotics for suspected incisional infection post appendectomy depends on various factors, including the type of appendicitis and the presence of complications 4, 5, 6, 7, 8.
• For nonperforated appendicitis, single-dose cefotetan or multiple-dose cefoxitin have been shown to be effective in preventing wound infections 4.
• For complicated appendicitis, the duration of postoperative antibiotic treatment does not appear to influence the incidence of postoperative intraabdominal abscesses and wound infections, and short-term postoperative antibiotic treatment may be preferred 6.
• A simplified once-daily regimen of ceftriaxone and metronidazole has been shown to be cost-effective and effective in treating pediatric appendicitis, including nonperforated, perforated, and abscessed cases 7.
• Cefazolin and metronidazole given as a single intravenous preparation may be a cost-effective alternative to cefoxitin or cefotetan for surgical antimicrobial prophylaxis of uncomplicated appendectomies 8.

Factors Influencing Antibiotic Choice

• The type of appendicitis (nonperforated, perforated, or gangrenous) 4, 5, 6.
• The presence of complications, such as intraabdominal abscesses or wound infections 5, 6, 7.
• The patient's age and weight, as well as any underlying medical conditions 7.
• The cost and availability of different antibiotic regimens 7, 8.

Antibiotic Regimens

• Cefotetan: a single dose of 2g preoperatively 4.
• Cefoxitin: a single dose of 2g preoperatively, or multiple doses postoperatively 4, 5.
• Ceftriaxone and metronidazole: a once-daily regimen of 50mg/kg and 20mg/kg, respectively 7.
• Cefazolin and metronidazole: a single intravenous preparation of 1g and 500mg, respectively 8.
• Ertapenem: a single dose of 1g preoperatively, or multiple doses postoperatively 7.