What are the new guidelines for managing appendicitis?

New Guidelines for Managing Appendicitis

Appendectomy remains the treatment of choice for acute appendicitis, though antibiotics alone can be considered for carefully selected patients with uncomplicated disease confirmed by CT scan, accepting a 23-37% failure rate requiring subsequent surgery. 1

Diagnosis and Risk Stratification

Use a step-up diagnostic approach starting with clinical and laboratory examination, progressing to imaging based on hospital resources and clinical scoring systems. 1

• Clinical scoring systems (such as the AIR score) should guide decision-making to reduce unnecessary imaging in low-risk patients and prevent negative surgical explorations. 1
• CT imaging is critical for distinguishing uncomplicated from complicated appendicitis and identifying high-risk features that predict antibiotic treatment failure. 2

Treatment Algorithm by Disease Severity

Uncomplicated Appendicitis

Surgical Management:

• Laparoscopic appendectomy is preferred over open surgery due to less postoperative pain, lower surgical site infection rates, shorter hospital stays, and faster return to work. 3
• Both laparoscopic and open approaches are viable when laparoscopic expertise is unavailable. 1
• Surgery should occur within 24 hours of admission to minimize complications. 3

Antibiotic-Only Management (Alternative for Selected Patients):

• Antibiotics can be offered as primary treatment for uncomplicated appendicitis, but this is less effective long-term with 23-37% requiring subsequent appendectomy and 11% experiencing recurrence at one year. 1, 4
• CT confirmation is essential before attempting antibiotic-only management—the diagnosis must be certain. 1
• High-risk CT findings predict failure: appendicolith, mass effect, or appendiceal diameter >13 mm are associated with ~40% antibiotic treatment failure and should prompt surgical management in fit patients. 2
• Acceptable antibiotic regimens: piperacillin-tazobactam monotherapy, or combination therapy with cephalosporins/fluoroquinolones plus metronidazole for 8-15 days. 2, 4

Complicated Appendicitis (Perforated, Abscess, Phlegmon)

For Periappendiceal Abscess:

• Percutaneous drainage plus antibiotics is recommended when interventional radiology is readily available. 1
• Laparoscopic management is preferred when advanced laparoscopic expertise exists, with low threshold for conversion. 1
• Surgery is indicated when percutaneous drainage is unavailable or fails. 1

Interval Appendectomy:

• Routine interval appendectomy is NOT recommended for young adults (<40 years) and children after successful non-operative treatment. 1
• Perform interval appendectomy only for recurrent symptoms. 1
• For patients ≥40 years treated non-operatively: colonoscopy and interval contrast-enhanced CT are recommended due to 3-17% incidence of appendicular neoplasms. 1

Antibiotic Therapy Guidelines

Perioperative Antibiotics for Surgery

Preoperative:

• Single dose of broad-spectrum antibiotics 0-60 minutes before incision is mandatory for all appendectomies. 1, 3
• Second or third-generation cephalosporins (cefoxitin, cefotetan) are appropriate for uncomplicated cases. 3

Postoperative for Uncomplicated Appendicitis:

• No postoperative antibiotics are recommended for uncomplicated appendicitis with adequate source control. 1, 3
• This applies to both adults and children. 1

Postoperative for Complicated Appendicitis:

• Limit antibiotics to 3-5 days maximum when adequate source control is achieved. 1, 3
• Broader-spectrum coverage is needed: piperacillin-tazobactam, ampicillin-sulbactam, or ticarcillin-clavulanate as monotherapy options. 3
• In children, switch to oral antibiotics after 48 hours with total therapy <7 days. 1, 3
• Metronidazole is unnecessary when using broad-spectrum aminopenicillins with β-lactam inhibitors or carbapenems. 3

Intraoperative Considerations

• Avoid routine intraoperative irrigation—it does not prevent intra-abdominal abscess formation and may be omitted. 1, 3
• Do not place drains following appendectomy for complicated appendicitis, as they provide no benefit and prolong hospitalization. 3
• Remove the appendix even if it appears normal during surgery when the patient was symptomatic. 3
• Routine histopathology is recommended to identify unexpected findings. 3

Special Populations

Pregnant and Immunosuppressed Patients:

• Timely surgical intervention is recommended to decrease complication risk rather than attempting antibiotic-only management. 5

Patients Unfit for Surgery:

• Antibiotics-first approach is recommended for unfit patients without high-risk CT findings. 2
• For unfit patients with high-risk CT findings: individualized perioperative risk assessment and patient preferences should guide decision-making. 2

Critical Pitfalls to Avoid

• Do not delay surgery beyond 24 hours from admission—this increases adverse outcomes. 3
• Do not attempt antibiotic-only treatment without CT confirmation of uncomplicated appendicitis. 1
• Do not use extended-spectrum antibiotics routinely—they offer no advantage over narrower-spectrum agents in children with surgically managed appendicitis. 3
• Do not perform routine interval appendectomy in young patients after successful non-operative management—only 12-24% will have recurrence. 1