From the Guidelines
Antibiotics can be discontinued following an appendectomy, with the timing depending on the type of appendicitis, as recommended by the 2020 update of the WSES Jerusalem guidelines 1.
Uncomplicated Appendicitis
For simple, non-perforated appendicitis, a single preoperative dose of antibiotics is sufficient, with no need for postoperative antibiotics, as stated in Recommendation 7.1 by the WSES guidelines 1. This approach serves as prophylaxis against surgical site infections.
Complicated Appendicitis
For complicated appendicitis (perforated or gangrenous), antibiotics should be continued postoperatively for 3-5 days or until clinical improvement occurs, as recommended by Recommendation 7.2 by the WSES guidelines 1. Discontinuation of antibiotics after 24 hours seems safe and is associated with shorter length of hospital stay, as demonstrated by a recent RCT 1. Common regimens include piperacillin-tazobactam or a combination of ceftriaxone plus metronidazole.
Rationale
The rationale for this approach is that antibiotics in simple appendicitis serve primarily as prophylaxis against surgical site infections, while in complicated cases, they treat the established intra-abdominal infection. Continuing antibiotics unnecessarily increases the risk of antibiotic resistance, Clostridioides difficile infection, and other adverse effects without providing additional clinical benefit, as supported by the "STOP-IT" RCT by Sawyer et al. 1.
Key points to consider:
- A single preoperative dose of broad-spectrum antibiotics is effective in decreasing wound infection and postoperative intra-abdominal abscess, regardless of the degree of inflammation of the removed appendix 1.
- Postoperative antibiotics are suggested for patients with complicated acute appendicitis, especially if complete source control has not been achieved 1.
- Discontinuation of antibiotics after 24 hours seems safe and is associated with shorter length of hospital stay and lower costs 1.
From the Research
Discontinuation of Antibiotics after Appendectomy
- The decision to discontinue antibiotics after an appendectomy depends on various factors, including the complexity of the appendicitis and the patient's overall health 2, 3, 4, 5.
- Studies have shown that shorter courses of antibiotics (3-6 days) may be as effective as longer courses (5-7 days) in preventing infectious complications after appendectomy for complicated appendicitis 3, 5.
- A post hoc analysis of the EAST Appendicitis "MUSTANG" Study found that giving ≤24 hours of antibiotics for complicated appendicitis was not inferior to a longer duration in preventing infectious complications after appendectomy 2.
- The APPIC trial aims to determine whether a short course (48 hours) of postoperative antibiotics is non-inferior to the current standard practice of 5 days for complex acute appendicitis 4.
- A study published in the British Journal of Surgery found that 3 days of antibiotic treatment was equally effective as 5 days in reducing postoperative infections after appendicectomy for complicated appendicitis 5.
Key Findings
- The optimal duration of antibiotics after appendectomy for complicated appendicitis is still unclear, but shorter courses may be as effective as longer courses 2, 3, 4, 5.
- The type of antibiotic regimen used may also impact the effectiveness of treatment, with oral antibiotics being a viable alternative to intravenous antibiotics in some cases 6.
- Further research is needed to determine the optimal duration and type of antibiotic treatment after appendectomy for complicated appendicitis 2, 3, 4, 5.