What is the management of perforated appendicitis?

Management of Perforated Appendicitis

Urgent appendectomy (laparoscopic or open) combined with immediate broad-spectrum intravenous antibiotics is the standard of care for perforated appendicitis with diffuse peritoneal contamination. 1

Immediate Surgical Intervention

Surgery should not be delayed once perforated appendicitis is diagnosed, as delayed intervention increases peritonitis severity, colonic wall inflammation, and requires more invasive procedures with poorer prognosis. 1 Both laparoscopic and open approaches are acceptable, with the choice dictated by surgeon expertise and available resources. 1

• Laparoscopic appendectomy is the preferred first-line approach when laparoscopic equipment and expertise are available, resulting in fewer wound infections compared to open appendectomy (though with slightly increased risk of intra-abdominal abscesses). 2
• Open approach may be preferable for perforated appendicitis with diffuse peritonitis, particularly in confirmed COVID-19 patients or when laparoscopic resources are limited. 3
• Surgery should be performed by the most experienced team member available. 3

Antibiotic Management

Broad-spectrum intravenous antibiotics must be initiated immediately upon diagnosis, covering enteric gram-negative organisms (particularly E. coli) and anaerobes (particularly Bacteroides species). 1, 2

Recommended IV Antibiotic Regimens:

Single-agent options:

• Piperacillin-tazobactam 2, 4
• Ampicillin-sulbactam 2
• Ertapenem 2, 5
• Imipenem-cilastatin 2
• Meropenem 2

Combination therapy options:

• Ampicillin + clindamycin (or metronidazole) + gentamicin 2
• Ceftriaxone + metronidazole 2
• Ciprofloxacin + metronidazole 2

Postoperative Antibiotic Duration:

• Total antibiotic duration should be 5-7 days for adults with perforated appendicitis, based on clinical response. 1
• Switch to oral antibiotics after 48 hours if clinically improving, with total therapy duration shorter than 7 days. 2, 6
• Discontinuation after 24 hours can be considered in selected cases with excellent source control and clinical improvement. 2

Alternative Management for Localized Disease

Patients with well-circumscribed periappendiceal abscesses can be managed conservatively with percutaneous drainage and antibiotics, avoiding immediate appendectomy. 1

• Percutaneous drainage is mandatory for abscesses ≥3 cm in diameter, combined with IV antibiotics as first-line treatment, with 70-90% efficacy rate. 6
• CT guidance should be used for deep collections to ensure safe access. 6
• Selected patients presenting several days after symptom onset with a periappendiceal phlegmon or small abscess not amenable to percutaneous drainage may be treated with antimicrobial therapy alone. 1
• Approximately 80% of patients successfully treated with percutaneous drainage do not require subsequent appendectomy. 6

Monitoring Requirements for Conservative Management:

• Serial clinical and imaging monitoring every 3-6 hours with absolute bowel rest and IV hydration. 1
• Clinical improvement should occur within 24 hours; if deterioration or progression to sepsis occurs, surgical treatment must not be delayed. 1
• Close multidisciplinary follow-up to detect sepsis or peritoneal signs is essential. 1

High-Risk Populations Requiring Surgery

The following populations should proceed directly to surgical management:

• Immunosuppressed patients and transplant recipients 1
• Patients with concomitant colonic diseases requiring surgery 1
• Elderly patients (age ≥65) have 55-70% perforation rates and threefold increase in mortality per decade, warranting aggressive surgical approach. 1, 2
• Patients with hemodynamic instability or diffuse peritonitis 3

Pediatric Considerations

• Children with perforated appendicitis should receive the same broad-spectrum coverage as adults, with extended-spectrum antibiotics offering no advantage over narrower-spectrum agents. 2
• The recommended pediatric regimen is ampicillin + clindamycin (or metronidazole) + gentamicin. 6
• Early transition to oral antibiotics after 48 hours with total therapy duration less than 7 days is appropriate. 1

Critical Pitfalls to Avoid

• Do NOT prolong antibiotics beyond 5-7 days when adequate source control has been achieved, as this increases costs, hospital stay, and antimicrobial resistance without improving outcomes. 2
• Do NOT add metronidazole unnecessarily when already using broad-spectrum agents like piperacillin-tazobactam or carbapenems that provide adequate anaerobic coverage. 2
• Do NOT delay surgery to determine COVID-19 status when appropriate PPE is available. 2
• Do NOT perform immediate appendectomy during the acute phase when a well-defined abscess is present; percutaneous drainage is preferred. 6
• Do NOT omit colonoscopy in patients ≥40 years old treated non-operatively, as this misses potential underlying neoplasms. 2

Mortality Risk Stratification

Perforated appendicitis carries approximately 5% mortality compared to <0.1% for non-gangrenous appendicitis, making timely source control critical. 1, 2 The case fatality rate after appendectomy is strongly influenced by age, reaching more than 16% in nonagenarians. 1