What is the management of appendicitis while awaiting surgical intervention?

From the Guidelines

Management of appendicitis while awaiting surgery should focus on supportive care, pain control, and antibiotics, with the goal of stabilizing the patient's condition and preventing complications, as recommended by the most recent guidelines 1. The primary objective is to control pain, prevent dehydration, and begin addressing the infection while awaiting definitive surgical treatment.

• Patients should remain NPO (nothing by mouth) to prepare for potential surgery and reduce stimulation of the gastrointestinal tract.
• Pain management typically includes intravenous analgesics such as morphine (0.1 mg/kg every 4 hours as needed) or hydromorphone (0.015 mg/kg every 4 hours as needed).
• Broad-spectrum antibiotics should be started promptly, with common regimens including piperacillin-tazobactam (3.375g IV every 6 hours), or a combination of ceftriaxone (1-2g IV daily) plus metronidazole (500mg IV every 8 hours), as supported by the 2020 update of the WSES Jerusalem guidelines 1.
• Intravenous fluids should be administered to maintain hydration, typically normal saline or lactated Ringer's at maintenance rates.
• Vital signs should be monitored regularly, with temperature checks every 4 hours to detect worsening infection.
• The patient should be positioned comfortably, often with knees flexed to reduce abdominal tension.
• Applying ice packs to the right lower quadrant may provide some comfort. In cases where surgery is delayed, non-operative management (NOM) with antibiotics may be considered for uncomplicated appendicitis, as suggested by the WSES guidelines 1, with close clinical and radiological surveillance. It is essential to note that the management of appendicitis while awaiting surgery should prioritize the patient's stability and comfort, with the ultimate goal of preventing morbidity and mortality, as emphasized by the World Journal of Emergency Surgery 1.

From the FDA Drug Label

INTRA-ABDOMINAL INFECTIONS Caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species. The management of appendicitis while awaiting surgical intervention may include the use of antibiotics such as ceftriaxone, as it is effective against some of the bacteria that can cause intra-abdominal infections, including appendicitis.

• The key points to consider are:
  • Ceftriaxone has been shown to be effective against certain bacteria that can cause intra-abdominal infections.
  • Surgical intervention is still necessary for the treatment of appendicitis.
  • Antibiotic therapy may be used to reduce the risk of infection while awaiting surgery 2

From the Research

Management of Appendicitis While Awaiting Surgical Intervention

The management of appendicitis while awaiting surgical intervention involves several key considerations, including the use of antibiotics and supportive care.

• The use of broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, has been shown to successfully treat uncomplicated acute appendicitis in approximately 70% of patients 3.
• In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy 3.
• For patients with uncomplicated appendicitis without risk factors for failure of non-operative management, a shared decision based on the patient's preferences should be made 4.
• In cases with risk factors, appendectomy is still the treatment recommended 4.
• If the diagnosis is uncertain or clinical symptoms are rather mild, antibiotic therapy should be started 4.

Supportive Care

Supportive care, including intravenous fluids and pain management, is also an important aspect of managing appendicitis while awaiting surgical intervention.

• The use of intravenous antibiotics and hydration to delay appendectomy until "normal business hours" has been shown to not have a significant impact on patient morbidity and mortality 5.
• Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management 6.

Special Considerations

There are certain patient populations that should be considered for surgical intervention, including pregnant patients and immunosuppressed patients.

• Pregnant patients as well as immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications 6.
• The timing of surgery, including the role of interval appendectomy, should be considered on a case-by-case basis 7.