Should a non-febrile patient with appendicitis continue their planned antibiotic course?

Antibiotic Management for Non-Febrile Patients with Appendicitis

In a non-febrile patient with appendicitis, the decision to continue antibiotics depends entirely on whether the appendicitis is complicated (perforated, abscess, or peritonitis) or uncomplicated—absence of fever supports early discontinuation in complicated cases and no postoperative antibiotics at all in uncomplicated cases. 1

Clinical Decision Algorithm Based on Appendicitis Type

For Uncomplicated (Non-Perforated) Appendicitis

• No postoperative antibiotics are indicated—only a single preoperative dose of broad-spectrum antibiotics (administered 0-60 minutes before surgical incision) is required 2, 3
• The absence of fever in this context confirms the uncomplicated nature and supports stopping antibiotics immediately postoperatively 1
• Multiple studies demonstrate that postoperative antibiotics in uncomplicated appendicitis do not reduce infection rates compared to preoperative prophylaxis alone 1

For Complicated (Perforated) Appendicitis with Adequate Source Control

• Discontinue antibiotics when clinical and laboratory criteria normalize, specifically:

  • Absence of fever (which your patient already demonstrates) 1
  • Normalization of leukocytosis 1
  • Evidence of clinical improvement 4

• The WSES 2020 Jerusalem Guidelines provide strong evidence (1B recommendation) that antibiotics should be limited to less than 7 days total, with most patients requiring only 3-5 days when adequate source control is achieved 2

• The landmark STOP-IT trial demonstrated that approximately 4 days of antibiotic therapy achieved identical outcomes to 8-day courses in complicated intra-abdominal infections including appendicitis 1, 2

• Antibiotics can be safely discontinued after 24 hours in patients with adequate source control who are clinically improving, which is associated with shorter hospital stays without increasing complications 4, 3

Key Clinical Criteria for Your Non-Febrile Patient

Your patient's absence of fever is a critical indicator for antibiotic discontinuation, particularly when combined with:

• Declining or normalized white blood cell count 1
• Clinical improvement (decreased pain, tolerating oral intake, normal bowel function) 1, 4
• Adequate source control achieved at surgery (complete appendectomy, no residual abscess) 3

Common Pitfalls to Avoid

• Do not confuse gangrenous with perforated appendicitis: Only truly perforated cases with inadequate source control require extended antibiotics beyond 3-5 days 3

• Do not extend antibiotics beyond 3-5 days even for complicated appendicitis when adequate source control has been achieved—longer courses provide no additional benefit and increase antibiotic-related complications including Clostridioides difficile infection 2, 4

• Do not continue antibiotics "just to complete the course" in uncomplicated appendicitis—this is unnecessary and contributes to antimicrobial resistance 1, 3

Specific Recommendations by Patient Age

Elderly Patients (≥65 years)

• For uncomplicated appendicitis: no postoperative antibiotics 1
• For complicated appendicitis: 3-5 days of broad-spectrum antibiotics, with discontinuation based on fever resolution and declining leukocytosis 1

Pediatric Patients (≥2 months)

• For uncomplicated appendicitis: no postoperative antibiotics 3
• For complicated appendicitis: early switch to oral antibiotics after 48 hours if clinically improving, with total duration less than 7 days 2, 3

Antibiotic Selection if Continuation is Indicated

If your patient has complicated appendicitis requiring continued therapy, appropriate regimens include:

• Piperacillin-tazobactam 2, 5
• Ampicillin-sulbactam 2
• Ceftriaxone plus metronidazole 2, 6

Transition to oral antibiotics is appropriate once the patient is clinically stable, afebrile, and tolerating oral intake 2

Evidence Quality Considerations

The guidelines are based on conditional recommendations with low-quality evidence due to lack of high-quality randomized trials specifically in elderly populations 1. However, the STOP-IT trial provides robust evidence (strong 1A recommendation) supporting shorter antibiotic courses in complicated intra-abdominal infections 2, 4. The absence of fever in your patient provides strong clinical support for early discontinuation regardless of the planned course duration.