What are the treatment guidelines for acute appendicitis?

From the Guidelines

The primary treatment for acute appendicitis is surgical removal of the appendix (appendectomy) via laparoscopic approach, which is preferred due to faster recovery, less pain, and fewer wound complications, as recommended by the 2020 update of the WSES Jerusalem guidelines 1. The treatment guidelines for acute appendicitis involve several key considerations, including the timing of surgery, the approach to surgery, and the use of antibiotics.

• Preoperative management includes intravenous fluids for hydration, nothing by mouth status, pain control with medications, and antibiotic therapy.
• Antibiotics should cover gram-negative and anaerobic organisms, typically with a regimen such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole.
• Laparoscopic appendectomy is recommended as the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis, where laparoscopic equipment and expertise are available 1.
• In cases of uncomplicated appendicitis, some patients may be candidates for non-operative management with antibiotics alone, though this approach carries a risk of recurrence.
• For patients with a periappendiceal abscess, initial management may include percutaneous drainage and antibiotics, with interval appendectomy considered after resolution of inflammation.
• Postoperatively, most patients can resume oral intake as tolerated and be discharged within 24-48 hours for laparoscopic procedures or 2-3 days for open surgeries, with oral antibiotics only necessary if perforation occurred.
• The 2020 update of the WSES Jerusalem guidelines also recommends against delaying appendectomy for acute appendicitis needing surgery beyond 24 h from the admission 1.
• Additionally, the guidelines suggest the adoption of outpatient laparoscopic appendectomy for uncomplicated appendicitis, provided that an ambulatory setting is available 1.
• The use of a single preoperative dose of broad-spectrum antibiotics is recommended, and postoperative antibiotics should be avoided in patients with uncomplicated appendicitis 1.
• In patients with complicated acute appendicitis, postoperative broad-spectrum antibiotics are suggested, especially if complete source control has not been achieved 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... In staphylococcal and other infections involving a collection of pus, surgical drainage should be carried out where indicated.

Prevention ... For prophylactic use in uncontaminated gastrointestinal surgery, vaginal hysterectomy, or abdominal hysterectomy, the following doses are recommended: Adults 2 grams administered intravenously just prior to surgery (approximately one-half to one hour before the initial incision)

The treatment guidelines for acute appendicitis involve surgical drainage and antibiotic prophylaxis. The recommended dose of cefoxitin for prophylactic use in uncontaminated gastrointestinal surgery, such as appendicitis, is 2 grams administered intravenously just prior to surgery. 2

From the Research

Treatment Guidelines for Acute Appendicitis

The treatment guidelines for acute appendicitis involve several approaches, including surgical removal of the inflamed appendix and antibiotic therapy. The choice of treatment depends on various factors, such as the severity of the condition and the patient's overall health.

Surgical Treatment

• The surgical removal of the inflamed appendix is the most common treatment for acute appendicitis 3, 4.
• Laparoscopic appendectomy is a minimally invasive procedure that has gained wide acceptance in recent years due to its benefits in terms of access trauma, postoperative pain, wound infection rates, and convalescence 3.
• Open appendectomy is also an option, but it is generally associated with more complications and a longer recovery time compared to laparoscopic appendectomy 4.
• Single-incision laparoscopic appendectomy is a newer technique that has shown promise in pediatric patients, but more research is needed to determine its effectiveness in adults 5.

Antibiotic Therapy

• Antibiotic therapy is an alternative treatment option for uncomplicated acute appendicitis, with some studies suggesting that it may be associated with fewer immediate complications compared to surgery 6, 7.
• However, antibiotic therapy may also be associated with a higher risk of subsequent failures, such as recurrence of symptoms or the need for surgery 6, 7.
• The choice of antibiotic regimen and the duration of treatment vary depending on the severity of the condition and the patient's overall health 7.

Patient Selection

• The selection of patients for surgical or antibiotic treatment depends on various factors, such as the severity of the condition, the patient's age, and their overall health 4, 7.
• Patients with complicated appendicitis, such as those with perforation or peritonitis, may require immediate surgery, while those with uncomplicated appendicitis may be candidates for antibiotic therapy 6, 7.