Antibiotic Duration for Non-Perforated Acute Appendicitis
For non-perforated acute appendicitis treated surgically, only a single preoperative dose of antibiotics is required, with NO postoperative antibiotics needed. 1, 2
Surgical Management (Standard Approach)
Preoperative Antibiotic Protocol
- Administer one dose of broad-spectrum antibiotics 0-60 minutes before surgical incision 1, 2
- Second or third-generation cephalosporins (cefoxitin or cefotetan) are the appropriate antibiotic choices 1, 3
- This single preoperative dose effectively decreases wound infection and postoperative intra-abdominal abscess rates 2
Postoperative Management
- No postoperative antibiotics are recommended for uncomplicated, non-perforated appendicitis 1, 2
- This represents a strong (1A) recommendation from the World Society of Emergency Surgery, the highest quality evidence available 1
- In pediatric patients, postoperative antibiotics have no role in reducing surgical site infection rates for uncomplicated cases 2
Non-Operative Management (Alternative Approach)
If antibiotics are chosen as primary treatment instead of surgery:
- Total antibiotic duration is 7-10 days 3
- Begin with minimum 48 hours of intravenous antibiotics, followed by oral antibiotics to complete the course 3
- Moxifloxacin 400 mg orally once daily for 7 days total is one acceptable regimen 3
- This approach is only appropriate for CT-confirmed uncomplicated appendicitis without appendicolith 3
Important Caveats for Non-Operative Management
- Recurrence risk is 23-39% over 5 years 3
- Approximately 11-14% experience recurrence at 1 year 3
- Success rates at 1 year are only 63-78% with antibiotics alone versus 97% with immediate appendectomy 4
- Presence of appendicolith increases failure rates to 47-60% 3
Critical Distinction: Perforated vs Non-Perforated
Do not confuse non-perforated with perforated appendicitis—this distinction determines antibiotic duration:
- Non-perforated (uncomplicated): Single preoperative dose only 1, 2
- Perforated (complicated): 3-5 days maximum postoperatively, even with adequate source control 1, 2
- Some evidence suggests even 24 hours postoperatively is safe for complicated cases and reduces hospital length of stay 1, 2
Common Pitfalls to Avoid
- Do not routinely prescribe postoperative antibiotics for non-perforated appendicitis—this provides no additional benefit and contributes to antimicrobial resistance 1, 2
- Do not extend antibiotic courses beyond necessary durations—prolonged courses offer no advantage over shorter regimens 2
- For patients ≥40 years treated non-operatively, colonoscopy and interval CT scan are recommended due to 3-17% incidence of appendiceal neoplasms 3, 2