What is the treatment for phlegmon?

Treatment of Phlegmon

The recommended treatment for phlegmon is non-operative management with broad-spectrum antibiotics and, if available, percutaneous drainage, particularly in settings where advanced laparoscopic expertise is not available. 1

Initial Management Approach

Non-Operative Management

• Non-operative management is considered a reasonable first-line treatment for phlegmon, especially when associated with conditions like appendicitis 1
• This approach includes:
  • Broad-spectrum antibiotic therapy covering both aerobic and anaerobic bacteria 1
  • Percutaneous drainage as an adjunct to antibiotics when accessible, though evidence for routine use is limited 1

Antibiotic Selection

• Recommended empiric antibiotic regimens include:
  • Single agents: ertapenem, meropenem, imipenem-cilastatin, or piperacillin-tazobactam 2, 3
  • Combination therapy: ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole 2
• For complicated infections, antibiotics that are effective against enteric gram-negative organisms and anaerobes including E. coli and Bacteroides species should be initiated promptly 1

Percutaneous Drainage

• For well-localized fluid collections, percutaneous drainage may be preferable to surgical drainage when feasible 2
• This approach can help achieve source control while avoiding more invasive surgical procedures 1

Surgical Management

When to Consider Surgery

• Laparoscopic surgery is a safe alternative to non-operative management in experienced hands 1
• Surgical approach may be associated with:
  • Shorter length of hospital stay
  • Reduced need for readmissions
  • Fewer additional interventions than conservative treatment 1

Surgical Technique

• Laparoscopic approach is suggested as the treatment of choice where advanced laparoscopic expertise is available 1
• Maintain a low threshold for conversion to open surgery if needed 1
• Incision and drainage is recommended as the primary intervention for abscess formation to provide adequate source control 2

Special Considerations

Age-Related Recommendations

• For patients ≥40 years old treated non-operatively for phlegmon:
  • Colonic screening with colonoscopy is recommended
  • Interval full-dose contrast-enhanced CT scan should be performed 1
  • This is due to the high incidence (3-17%) of appendicular neoplasms in this age group 1

Follow-up After Non-Operative Management

• Routine interval appendectomy is not recommended after successful non-operative management for complicated appendicitis with phlegmon in young adults (<40 years old) and children 1
• Interval appendectomy should be reserved for patients who develop recurrent symptoms 1
• The reported rate of recurrence after non-surgical treatment for perforated appendicitis and phlegmon ranges from 12% to 24% 1, 4

Duration of Treatment

• For complicated infections, antibiotics should not be prolonged longer than 3-5 days postoperatively with adequate source control 1
• Duration typically ranges from 5-14 days depending on clinical response and severity 2

Potential Complications

• Recurrence of infection (12-24% after non-surgical treatment) 1, 4
• Development of chronic fistulas requiring specialized management 2
• Risk of underlying neoplasm, particularly in patients ≥40 years old 1

Pitfalls to Avoid

• Failing to obtain appropriate cultures from the infection site to guide targeted antibiotic therapy 2
• Overlooking the need for imaging before surgical intervention in complex cases 2
• Continuing antibiotics beyond the recommended duration when adequate source control has been achieved 1