Antibiotic Duration for Perforated Appendicitis
For patients with perforated appendicitis, antibiotics should be administered for 3-5 days postoperatively when adequate source control has been achieved. 1
Adult Patients
- A single preoperative dose of broad-spectrum antibiotics should be administered 0-60 minutes before surgical incision to decrease wound infection and postoperative intra-abdominal abscess 1
- Postoperative antibiotics are indicated for perforated appendicitis, especially when complete source control has not been achieved 1
- Recent evidence suggests that discontinuation of antibiotics after just 24 hours following appendectomy does not result in worse outcomes in complicated appendicitis with adequate source control, and is associated with shorter hospital stays and lower costs 1
- For most adult patients, a fixed-duration antibiotic therapy of 3-5 days is sufficient and produces similar outcomes to longer courses 1, 2
- Extending antibiotic therapy beyond 3-5 days does not improve outcomes when adequate source control has been achieved 2
Pediatric Patients
- Early switch (after 48 hours) to oral antibiotics in children with complicated appendicitis is safe and effective 1, 2
- Total duration of antibiotic therapy in children should be shorter than 7 days 1, 3
- A shortened course (5-8 days) of antibiotics shows similar outcomes to prolonged courses (10-14 days) in pediatric patients 3
- Children may be safely discharged home on oral antibiotics when enteral intake is tolerated, regardless of fever or leukocytosis 4
Antibiotic Selection
- For non-critically ill patients, piperacillin/tazobactam is recommended as first-line therapy 2, 5
- Alternative regimens include ceftriaxone plus metronidazole, which has been shown to be cost-effective and efficacious 6, 7
- For beta-lactam allergies, options include ciprofloxacin plus metronidazole or moxifloxacin 5
- In children, amoxicillin/clavulanate is preferred for oral therapy due to better tolerability 3
Monitoring Response
- Continue antibiotics until resolution of fever, leukocytosis, and ileus 5
- Monitor for signs of treatment failure including persistent fever, increasing abdominal pain, or worsening leukocytosis 5
- Consider imaging to rule out abscess formation if clinical improvement is not observed 5
Common Pitfalls
- Unnecessarily prolonged antibiotic courses increase the risk of antimicrobial resistance and adverse effects without improving outcomes 2, 5
- Inadequate anaerobic coverage can lead to treatment failure 5
- Delaying antibiotic administration after diagnosis can increase morbidity 5
- Despite evidence supporting shorter courses, prolonged antibiotic regimens are still routinely prescribed in clinical practice 3