What is the day-to-day management of post-operative ruptured acute appendicitis?

From the Guidelines

The day-to-day management of post-operative ruptured acute appendicitis should focus on infection control with postoperative broad-spectrum antibiotics for 3-5 days, especially if complete source control has not been achieved, as recommended by the 2020 WSES Jerusalem guidelines 1. The management plan includes:

• Intravenous antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g daily plus metronidazole 500mg every 8 hours, for 3-5 days depending on clinical response, as suggested by the guidelines 1.
• Pain management with IV medications like morphine 2-4mg every 4 hours or hydromorphone 0.5-1mg every 4 hours as needed, transitioning to oral analgesics such as acetaminophen 650mg every 6 hours and oxycodone 5-10mg every 4-6 hours as pain decreases.
• Fluid resuscitation with isotonic crystalloids maintained until the patient tolerates adequate oral intake.
• Diet progression follows a stepwise approach, starting with clear liquids on postoperative day 1-2, advancing to full liquids, then to a regular diet as bowel function returns, indicated by passing flatus or having a bowel movement.
• Wound care is crucial, especially with open wounds that may require packing changes every 12-24 hours.
• Patients should be monitored for complications such as intra-abdominal abscess formation, which may present as persistent fever, increasing pain, or elevated white blood cell count, potentially requiring percutaneous drainage, as noted in the guidelines 1.
• Early ambulation is encouraged, starting with sitting up and dangling legs at the bedside on postoperative day 1, progressing to walking in the hallway multiple times daily.
• Most patients can be discharged when they tolerate oral intake, have adequate pain control with oral medications, show no signs of ongoing infection, and demonstrate appropriate wound healing, typically within 5-7 days after surgery for complicated appendicitis. The recommendation for 3-5 days of postoperative antibiotics is based on the high-quality evidence from the 2020 WSES Jerusalem guidelines 1, which suggests that longer postoperative courses do not prevent surgical site infections (SSI) compared to 2 days of antibiotics. Some studies, such as the meta-analysis by Van den Boom et al. 1, have shown that longer postoperative antibiotic courses do not prevent SSI, while others, such as the RCT by Sawyer et al. 1, have demonstrated that fixed-duration antibiotic therapy (approximately 4 days) has similar outcomes to longer courses of antibiotics. However, the most recent and highest-quality study, the 2020 WSES Jerusalem guidelines 1, recommends against prolonging antibiotics longer than 3-5 days postoperatively in case of complicated appendicitis with adequate source control.

From the FDA Drug Label

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 day-to-day management of post-operative ruptured acute appendicitis is not directly addressed in the provided FDA drug label. However, the label does mention the treatment of complicated intra-abdominal infections (IAI), which includes perforated or complicated appendicitis, with ertapenem.

• Clinical success rates for ertapenem in treating IAI were 83.7% in the evaluable per protocol (EPP) analysis.
• The label does not provide specific guidance on the day-to-day management of post-operative ruptured acute appendicitis, but it does suggest that ertapenem may be an effective treatment option for complicated IAI, including perforated or complicated appendicitis 2.

From the Research

Day-to-Day Management of Post-Operative Ruptured Acute Appendicitis

• The management of post-operative ruptured acute appendicitis involves prompt surgical intervention, as prevention is not possible 3
• The treatment approach depends on the presentation of the patient and whether the disease is uncomplicated or complicated 4
• Complicated acute appendicitis, which includes ruptured appendicitis, should undergo timely surgical intervention 4
• Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management 4

Antibiotic Management

• A dual antibiotic regimen consisting of ceftriaxone and metronidazole has been shown to be a more efficient and cost-effective antibiotic management compared to a traditional triple antibiotic regimen in children with perforated appendicitis 5, 6
• The use of a dual antibiotic regimen may be associated with higher rates of wound infections and change in antibiotic therapy, although this is not statistically significant 6

Post-Operative Care

• Post-operative care may involve the use of surgical drains to reduce postoperative complications, although this carries an increased risk of drain occlusion, fistula formation, and paralytic ileus 7
• The closure of the appendiceal stump is a critical aspect of appendectomy and can be achieved with the help of endoclips, sutures, staples, and endoloops 7