What is the medical management of acute appendicitis?

From the Guidelines

The medical management of acute appendicitis involves a single preoperative dose of broad-spectrum antibiotics in patients undergoing appendectomy, with postoperative antibiotics suggested for complicated cases, and non-operative management with antibiotics considered for select cases of uncomplicated appendicitis. The management of acute appendicitis is multifaceted, involving surgical and non-surgical approaches. For patients undergoing appendectomy, a single preoperative dose of broad-spectrum antibiotics is recommended 1, as it has been shown to decrease wound infection and postoperative intra-abdominal abscess. In cases of complicated acute appendicitis, postoperative broad-spectrum antibiotics are suggested, especially if complete source control has not been achieved, but antibiotics should not be prolonged longer than 3-5 days postoperatively 1. Non-operative management with antibiotics is considered a viable option for select cases of uncomplicated appendicitis, with studies showing that the majority of patients with uncomplicated acute appendicitis can be treated with an antibiotic-first approach 1. The success of non-operative management requires careful patient selection, excluding patients with gangrenous appendicitis, abscesses, and diffuse peritonitis. Patients with uncomplicated appendicitis who are suitable candidates for non-operative management may receive intravenous antibiotics such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ertapenem, followed by oral antibiotics to complete a 7-10 day course. Key considerations in the medical management of acute appendicitis include:

• Patient selection for non-operative management
• Antibiotic regimen and duration
• Monitoring for clinical improvement and potential complications
• Surgical intervention for cases with perforation, abscess, peritonitis, or appendicolith. Overall, the goal of medical management in acute appendicitis is to control the bacterial infection, allow the inflammation to resolve, and prevent complications, with the most recent and highest quality evidence guiding treatment decisions 1.

From the FDA Drug Label

Piperacillin and Tazobactam for Injection is indicated in adults and pediatric patients (2 months of age and older) for the treatment of appendicitis (complicated by rupture or abscess) and peritonitis caused by beta-lactamase producing isolates of Escherichia coli or the following members of the Bacteroides fragilis group: B. fragilis, B. ovatus, B. thetaiotaomicron, or B. vulgatus.

The medical management of acute appendicitis includes the use of piperacillin-tazobactam (IV) for the treatment of appendicitis complicated by rupture or abscess. The recommended dosage is 3.375 grams every six hours [totaling 13.5 grams (12.0 grams piperacillin and 1.5 grams tazobactam)], to be administered by intravenous infusion over 30 minutes, for a duration of 7 to 10 days 2.

• Key points:
  • Piperacillin-tazobactam (IV) is indicated for the treatment of appendicitis complicated by rupture or abscess.
  • The recommended dosage is 3.375 grams every six hours.
  • The treatment duration is 7 to 10 days.

From the Research

Medical Management of Acute Appendicitis

The medical management of acute appendicitis involves both surgical and non-surgical approaches.

• The clinical diagnosis of acute appendicitis is based on history, physical examination, laboratory evaluation, and imaging 3.
• Laparoscopic appendectomy remains the most common treatment for acute appendicitis, but increasing evidence suggests that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 3, 4, 5.
• Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluoroquinolones with metronidazole, can be used to treat uncomplicated acute appendicitis 3, 5.
• Specific imaging findings on computed tomography (CT), such as appendiceal dilatation or presence of appendicoliths, can identify patients for whom an antibiotics-first management strategy is more likely to fail 3.
• The treatment success rate at 1 year was 70.2% for patients treated with oral antibiotics and 73.8% for patients treated with intravenous followed by oral antibiotics 6.

Selection of Patients for Antibiotic Therapy

The selection of patients for antibiotic therapy depends on various factors, including:

• The presence of high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix greater than 13 mm 3.
• The patient's fitness for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity 3.
• Patient preferences and perioperative risk assessment 3.
• The risk of complications, such as perforation, peritonitis, and surgical wound infections, which is lower with antibiotic therapy than with immediate appendectomy 4.

Comparison of Antibiotic Regimens

Different antibiotic regimens have been compared in various studies, including:

• Oral moxifloxacin vs intravenous ertapenem plus oral levofloxacin 6.
• Piperacillin-tazobactam monotherapy vs combination therapy with either cephalosporins or fluoroquinolones with metronidazole 3, 5.
• The optimal antibiotic regimen is not known, and further studies are needed to determine the most effective treatment strategy 6, 7.