What is the recommended treatment for a contained appendiceal (appendix) perforation?

Treatment of Contained Appendiceal Perforation

For contained appendiceal perforation (appendiceal abscess), perform laparoscopic appendectomy as soon as possible followed by 3-5 days of broad-spectrum antibiotics, or alternatively, use percutaneous drainage plus antibiotics for abscesses ≥3 cm if the patient wishes to avoid immediate surgery. 1, 2

Surgical Management Approach

Laparoscopic appendectomy is the preferred first-line treatment when laparoscopic expertise is available, as it results in fewer wound infections compared to open appendectomy, though with a slightly increased risk of intra-abdominal abscesses. 1

• Early appendectomy (within 24 hours) demonstrates superior outcomes compared to initial non-operative management, with significantly lower rates of bowel resection (3.3% vs 17.1%). 1
• Place an abdominal drain intraoperatively when dealing with perforation, abscess, or peritonitis. 3

Non-Operative Management Option

For selected patients with contained perforation (appendiceal abscess ≥3 cm), percutaneous drainage with antibiotics is a safe alternative that can avoid appendectomy in approximately 64% of cases. 4

• Ultrasound-guided percutaneous drainage combined with IV antibiotics significantly shortens hospital stay by an average of 6.4 days compared to antibiotics alone. 4
• Antibiotics alone (without drainage) for abscesses ≥3 cm results in high failure rates requiring surgery, with only 8% avoiding appendectomy long-term. 4
• Do NOT use non-operative management if there is diffuse peritonitis or suspected free perforation on CT scan. 3

Antibiotic Regimen

Initiate broad-spectrum IV antibiotics immediately that cover enteric gram-negative organisms (E. coli) and anaerobes (Bacteroides species). 1, 2

Recommended IV Options:

• Single-agent regimens: Piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate, imipenem-cilastatin, ertapenem, or meropenem. 1, 2
• Combination therapy: Ceftriaxone + metronidazole, OR ciprofloxacin + metronidazole, OR ampicillin + clindamycin (or metronidazole) + gentamicin. 1, 2, 5

Transition to Oral Antibiotics:

• Switch to oral antibiotics after 48 hours if the patient is clinically improving and tolerating oral intake. 1, 2
• Oral options include amoxicillin-clavulanate, fluoroquinolones with metronidazole, or cephalosporins with metronidazole. 2
• Children can be safely discharged on oral trimethoprim/sulfamethoxazole plus metronidazole when tolerating oral intake, regardless of persistent fever or leukocytosis. 6, 7

Duration:

• Total antibiotic duration should be 3-5 days postoperatively after adequate surgical source control. 1, 2
• Discontinue antibiotics when the patient is afebrile, has normalizing white blood cell counts, and has returned to normal gastrointestinal function. 3
• For non-operatively managed patients, total duration is typically 8-15 days. 2

Special Population Considerations

All patients ≥40 years old with contained perforation must undergo colonic screening with colonoscopy due to higher risk of appendiceal neoplasms, plus an interval full-dose contrast-enhanced CT scan. 3, 1, 2

• Routine interval appendectomy is NOT recommended after successful non-operative management in young adults (<40 years) and children. 1
• In elderly patients, laparoscopic appendectomy is preferred due to reduced length of stay, morbidity, and costs. 3

Common Pitfalls to Avoid

• Do not prolong antibiotics beyond 3-5 days when adequate source control has been achieved—this increases costs, hospital stay, and antimicrobial resistance without improving outcomes. 1, 2
• Do not add metronidazole unnecessarily when already using broad-spectrum agents like piperacillin-tazobactam or carbapenems that provide adequate anaerobic coverage. 1, 2
• Do not use antibiotics alone for abscesses ≥3 cm—either perform percutaneous drainage or proceed directly to surgery, as antibiotics alone have high failure rates. 4
• Do not omit colonoscopy in patients ≥40 years old treated non-operatively, as this misses potential underlying neoplasms. 1, 2
• Do not subject patients with persistent signs of infection to prolonged antimicrobial therapy without clinical investigation to determine the cause—they need diagnostic workup, not arbitrary antibiotic changes. 3