What is the daily management of acute appendicitis (inflammation of the appendix)?

From the Guidelines

The daily management of acute appendicitis typically begins with diagnosis followed by prompt surgical intervention, with appendectomy being the treatment of choice, as recommended by the 2020 WSES Jerusalem guidelines 1. The initial management includes keeping the patient nil by mouth (NPO), providing intravenous fluids, and administering antibiotics. Common antibiotic regimens include piperacillin-tazobactam or a combination of ceftriaxone and metronidazole. Pain management with acetaminophen and/or morphine is also appropriate.

• The diagnosis of acute appendicitis is typically confirmed by imaging studies, such as an abdominal CT scan or ultrasound.
• Initial management includes: + Keeping the patient nil by mouth (NPO) + Providing intravenous fluids (typically normal saline at maintenance rates) + Administering antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours + Pain management with acetaminophen 1g IV every 6 hours and/or morphine 0.1mg/kg IV as needed
• The definitive treatment is typically appendectomy, either laparoscopic or open, performed within 24-48 hours of diagnosis, as supported by the WSES guidelines 1 and other studies 2, 3.
• Postoperatively, patients usually remain hospitalized for 1-2 days for uncomplicated cases, continuing antibiotics for 24 hours after surgery. For complicated appendicitis (perforation, abscess), antibiotic duration extends to 5-7 days, as recommended by the 2020 WSES Jerusalem guidelines 1.
• Patients can typically resume oral intake as tolerated after surgery, advance to regular diet, and be discharged when tolerating oral intake with adequate pain control.
• Follow-up should occur within 1-2 weeks to assess wound healing and recovery. This approach is effective because prompt surgical intervention prevents progression to perforation, while antibiotics address the bacterial infection associated with appendicitis, ultimately reducing morbidity, mortality, and improving quality of life, as supported by the highest quality and most recent study available 1.

From the FDA Drug Label

The second trial enrolled 112 patients and compared ertapenem (15 mg/kg IV every 12 hours in patients 3 months to 12 years of age, and 1 g IV once a day in patients 13 to 17 years of age) to ticarcillin/clavulanate (50 mg/kg for patients <60 kg or 3. 0 g for patients >60 kg, 4 or 6 times a day) up to 14 days for the treatment of complicated intra-abdominal infections (IAI) and acute pelvic infections (API). In patients treated for IAI (primarily patients with perforated or complicated appendicitis), the clinical success rates were 83.7% (36/43) for ertapenem and 63. 6% (7/11) for ticarcillin/clavulanate in the EPP analysis.

The daily management of acute appendicitis (inflammation of the appendix) may involve the use of ertapenem as part of the treatment regimen.

• The clinical success rates for ertapenem in treating complicated intra-abdominal infections, including appendicitis, were 83.7% in one study 4.
• Ertapenem may be administered at a dose of 1 g IV once a day for patients 13 to 17 years of age, and 15 mg/kg IV every 12 hours for patients 3 months to 12 years of age.
• The treatment duration may be up to 14 days. However, the specific details of daily management, such as the exact dosage and duration of treatment, may vary depending on the individual patient and the severity of their condition.

From the Research

Daily Management of Acute Appendicitis

The daily management of acute appendicitis involves a combination of surgical and non-surgical approaches, depending on the severity of the condition and the patient's overall health.

• For uncomplicated appendicitis, approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission 5.
• The other 10% that fail to respond to antibiotics require a rescue appendectomy 5.
• Recurrence rates of non-operated patients within 1 year are as high as 20-30% 5.
• In cases with risk factors, appendectomy is still the treatment recommended 5.
• If the diagnosis is uncertain or clinical symptoms are rather mild, antibiotic therapy should be started 5.

Antibiotic Therapy

Antibiotic therapy is an essential component of the management of appendicitis.

• A study comparing single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children found that the single daily dosing regimen was more simple and cost-effective without compromising infection control 6.
• The use of antibiotics as the only strategy to treat appendicitis has the purpose of lowering costs and diminishing complications related to surgery or the resection of the organ 7.

Surgical Intervention

Surgical intervention is often necessary for complicated appendicitis.

• Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management 8.
• Certain patient populations, such as pregnant patients and immunosuppressed patients, should undergo timely surgical intervention to decrease the risk of complications 8.
• A practice management guideline from the Eastern Association for the Surgery of Trauma conditionally recommends against routine interval appendectomy in otherwise asymptomatic patients with appendiceal abscess or phlegmon initially managed without appendectomy 9.

Treatment Approaches

The treatment approach for acute appendicitis depends on the presentation of the patient and dividing it into uncomplicated and complicated disease.

• Uncomplicated appendicitis can be managed with antibiotics alone, while complicated appendicitis requires timely surgical intervention 8.
• Nonoperative management of uncomplicated appendicitis without fecalith can be managed with antibiotics alone 8.
• The ideal management of appendicitis remains controversial and will depend on the clinical characteristics of each patient and the resources available 7.