From the Guidelines
Empiric antibiotics can be administered for suspected acute appendicitis without performing a computed tomography (CT) scan, especially in cases with classic clinical presentation or when imaging is unavailable or contraindicated, as supported by the 2020 update of the WSES Jerusalem guidelines 1. The typical regimen includes broad-spectrum antibiotics that cover gram-negative and anaerobic organisms, such as Amoxicillin/clavulanate 1.2–2.2 g 6-hourly or ceftriaxone 2 g 24-hourly + metronidazole 500 mg 6-hourly, as advised by the 2017 WSES guidelines 1. Some key points to consider when administering empiric antibiotics for suspected acute appendicitis include:
- The importance of prompt initiation of antibiotics once appendicitis is suspected, even before definitive diagnosis or surgical intervention 1
- The need for clinical reassessment, as worsening symptoms despite antibiotics may indicate the need for urgent surgical intervention regardless of imaging status
- The potential for antibiotics alone to not be the definitive treatment for acute appendicitis in most cases, but rather to control infection while preparing for surgery or as a temporizing measure 1
- The ongoing research, such as the APPAC II and APPAC III trials, which aim to assess the safety and feasibility of per-oral antibiotic monotherapy and the role of antibiotics in the resolution of CT-diagnosed uncomplicated acute appendicitis, respectively 1
From the Research
Administration of Empiric Antibiotics for Suspected Acute Appendicitis
- Empiric antibiotics can be administered for suspected acute appendicitis without performing a computed tomography (CT) scan in certain cases, as suggested by studies 2, 3.
- The decision to administer empiric antibiotics should be based on the patient's risk factors, clinical presentation, and laboratory results, as outlined in the study 4.
- The Alvarado score can be used to select patients for early treatment with surgery or outpatient antibiotics, as described in the study 3.
Factors Influencing the Decision to Administer Empiric Antibiotics
- The presence of high-risk criteria, such as sepsis, comorbidities, and health-care-associated appendicitis, should be considered when deciding whether to administer empiric antibiotics 4.
- CT findings, such as appendiceal diameter, appendicolith, and intra-abdominal free fluid, can also influence the decision to administer empiric antibiotics or proceed with surgical treatment 5.
- The severity of mural enhancement and the CT appendicitis score can also be used to predict the success of medical treatment and guide the decision to administer empiric antibiotics 5.
Treatment Approaches for Acute Appendicitis
- Uncomplicated acute appendicitis can be managed with antibiotics alone, as suggested by studies 2, 6.
- Complicated acute appendicitis, on the other hand, requires timely surgical intervention, as outlined in the study 6.
- Patients with high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix, should be recommended for surgical management, as suggested by the study 2.