From the Guidelines
The management of acute appendicitis should prioritize a non-operative approach with antibiotics as the first line of treatment for uncomplicated cases, with laparoscopic appendectomy reserved for cases that fail non-operative management or are complicated, as this approach has been shown to reduce overall complication rates and improve quality of life. When appendicitis is suspected based on symptoms like right lower quadrant pain, nausea, and fever, patients should be evaluated with blood tests (looking for elevated white blood cell count) and imaging studies (typically ultrasound or CT scan) 1. Once diagnosed, patients with uncomplicated appendicitis can be treated with intravenous antibiotics such as ertapenem 1g daily for 3 days followed by oral amoxicillin-clavulanate 875/125mg twice daily for 7 days, with a recurrence rate of up to 39% after 5 years 1.
Key Considerations
- The success of non-operative management (NOM) requires careful patient selection, with criteria including CRP < 60 g/L, WBC < 12 × 10^9/L, and age < 60 years 1.
- Patients with appendicoliths are at higher risk of treatment failure and perforation, and may require closer monitoring or alternative treatment approaches 1.
- Complicated appendicitis with perforation or abscess formation requires longer antibiotic courses (5-7 days) and possibly percutaneous drainage before definitive surgery 1.
- Laparoscopic appendectomy is preferred over open surgery when possible, as it results in less pain, shorter hospital stays, and quicker recovery 1.
Treatment Approach
- Non-operative management with antibiotics is a reasonable first-line treatment for appendicitis with phlegmon or abscess, with percutaneous drainage as an adjunct to antibiotics if accessible 1.
- Laparoscopic surgery in experienced hands is a safe and feasible first-line treatment for appendiceal abscess, being associated with fewer readmissions and fewer additional interventions than conservative treatment, with a comparable hospital stay 1.
- Postoperative care includes pain management with acetaminophen and NSAIDs as first-line agents, early mobilization, and resumption of oral intake as tolerated.
Evidence Summary
The most recent and highest quality study, published in 2021, supports the use of non-operative management with antibiotics as the first line of treatment for uncomplicated acute appendicitis 1. This approach has been shown to reduce overall complication rates and improve quality of life, with a recurrence rate of up to 39% after 5 years 1. The 2020 update of the WSES Jerusalem guidelines also supports the use of non-operative management with antibiotics for uncomplicated acute appendicitis, with careful patient selection and monitoring 1.
From the FDA Drug Label
- 1 Intra-abdominal Infections 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 management of acute appendicitis includes the use of piperacillin and tazobactam for the treatment of appendicitis complicated by rupture or abscess, as well as peritonitis caused by specific bacterial isolates.
- The treatment is indicated in adults and pediatric patients (2 months of age and older).
- Piperacillin and tazobactam should be used to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
- The usual duration of treatment is from 7 to 10 days 2.
From the Research
Management of Acute Appendicitis
The management of acute appendicitis can be divided into two main approaches: surgical and non-surgical.
- Surgical management: Laparoscopic appendectomy remains the most common treatment for acute appendicitis 3.
- Non-surgical management: Increasing evidence suggests that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients 3, 4, 5.
Patient Selection for Non-Surgical Management
Patient selection is crucial for non-surgical management of acute appendicitis.
- Patients without high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix, can be considered for antibiotics as first-line therapy 3.
- Patients with high-risk CT findings should be recommended for surgical management if they are fit for surgery 3.
- Unfit patients without high-risk CT findings can be considered for antibiotics-first approach, and surgery may be considered if antibiotic treatment fails 3.
Antibiotic Regimens
Various antibiotic regimens have been studied for the treatment of acute appendicitis.
- Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, have been shown to be effective 3, 5.
- The duration of antibiotic treatment can vary, but typically ranges from 7 to 10 days 4, 5.
Special Considerations
Certain patient populations require special consideration when managing acute appendicitis.