What is the recommended antibiotic course for a patient with classical appendicitis undergoing surgery?

Antibiotic Duration for Classical Appendicitis Undergoing Surgery

For uncomplicated (non-perforated) appendicitis, give a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before incision and stop—no postoperative antibiotics are needed. 1, 2

Uncomplicated Appendicitis Protocol

• Administer one preoperative dose of a second or third-generation cephalosporin (cefoxitin or cefotetan) 0-60 minutes before surgical incision 1, 2, 3
• Postoperative antibiotics are strongly contraindicated for uncomplicated appendicitis—they provide no benefit and only increase adverse effects and resistance 1, 2, 4
• This represents the highest quality evidence (1A recommendation) from the World Society of Emergency Surgery 1, 2

Complicated (Perforated) Appendicitis Protocol

If perforation or gangrene is found intraoperatively, continue postoperative antibiotics for a maximum of 3-5 days, or even just 24 hours if adequate source control is achieved. 1, 5, 4

Duration Guidelines for Complicated Cases:

• 24 hours of postoperative antibiotics is safe and effective, reducing hospital length of stay without increasing complications 1, 5, 4
• If extending beyond 24 hours, discontinue at 3-5 days maximum when adequate source control has been achieved 1, 5, 6
• Do not extend antibiotics beyond 5 days—longer courses provide zero additional benefit 1, 5
• Meta-analysis showed no difference in intra-abdominal abscess rates between ≤3 days versus >3 days (OR 0.81) 1, 2
• The STOP-IT trial demonstrated that 4-day courses produced identical outcomes to 8-day courses in complicated intra-abdominal infections 1, 2

Antibiotic Selection for Complicated Cases:

• Piperacillin-tazobactam 3.375 g IV every 6 hours is the preferred single-agent regimen 5
• Alternative regimens include carbapenems or combination therapy with ceftriaxone/cefotaxime/cefepime PLUS metronidazole 5
• Avoid ampicillin-sulbactam due to high E. coli resistance rates (>20%) 5

Critical Distinction: The Key to Correct Management

• The distinction between non-perforated and perforated appendicitis is absolutely critical—only complicated cases require postoperative antibiotics 2, 4
• This determination should be made intraoperatively based on surgical findings 1, 6
• If the appendix is inflamed but intact (non-perforated), stop antibiotics immediately postoperatively 1, 2, 4

Common Pitfalls to Avoid

• Do not reflexively continue antibiotics postoperatively for all appendectomies—this is the most common error and represents outdated practice 1, 2
• Do not confuse prophylactic timing (preoperative) with therapeutic duration (postoperative for complicated cases only) 1, 4
• Do not use arbitrary 7-day courses—even for complicated appendicitis, this exceeds evidence-based recommendations 1, 2, 5
• Prophylactic administration should be stopped within 24 hours for surgical prophylaxis in general, as continuing antibiotics increases adverse reactions without reducing infection 3

Answer to Your Specific Question

Among your four options:

• Preop + 1 day postop: Correct for complicated appendicitis (preferred based on most recent evidence) 1, 5, 4
• Preop only (essentially 0 days postop): Correct for uncomplicated appendicitis 1, 2, 4
• Preop + 3-5 days postop: Acceptable maximum for complicated appendicitis with inadequate source control 1, 5, 6
• Preop + 7 days postop: Excessive and not evidence-based—provides no additional benefit 1, 2, 5