What is the recommended conservative antibiotic regimen for acute appendicitis in a pregnant patient?

From the Guidelines

For pregnant patients with acute appendicitis, a conservative antibiotic regimen may be considered in select cases of uncomplicated appendicitis, with the most recent evidence from 2021 suggesting that non-operative management (NOM) with antibiotic therapy can be a safe and effective approach 1.

Key Considerations

• The recommended antibiotic regimen includes intravenous piperacillin-tazobactam or ceftriaxone plus metronidazole, which targets common gastrointestinal pathogens including E. coli, Bacteroides, and other anaerobes while considering pregnancy safety.
• Close monitoring is essential with daily physical examinations, white blood cell counts, and C-reactive protein measurements, as well as fetal monitoring appropriate for gestational age.
• If clinical deterioration occurs, immediate surgical intervention is necessary.

Antibiotic Regimen

• Intravenous piperacillin-tazobactam 3.375g every 6 hours or ceftriaxone 2g daily plus metronidazole 500mg every 8 hours for 48-72 hours.
• Followed by oral antibiotics such as amoxicillin-clavulanate 875/125mg twice daily for a total 7-10 day course if clinical improvement occurs.

Important Notes

• Each case requires individualized assessment based on gestational age, severity of appendicitis, and maternal condition, with multidisciplinary input from obstetrics, surgery, and maternal-fetal medicine specialists.
• The risk of recurrence after NOM with antibiotics is up to 39% after 5 years, but this does not appear to be pivotal in the decision-making process during the pandemic 1.
• The 2021 guidelines from the World Journal of Emergency Surgery suggest that NOM with antibiotics can be a safe tool to avoid surgery for uncomplicated acute appendicitis during the pandemic, and postpone it, eventually, to treat a recurrence 1.

From the Research

Conservative Antibiotics Regimen for Acute Appendicitis in Pregnant Patients

• The use of conservative antibiotics regimen for acute appendicitis in pregnant patients has been studied, with some research suggesting it as an acceptable option, especially in uncomplicated cases 2.
• A study published in the World Journal of Surgery found that conservative management of acute appendicitis during pregnancy resulted in acceptable outcomes, with a low incidence of fetal loss and no maternal deaths or serious complications 2.
• Another study published in JAMA noted that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients, but the effectiveness of this approach may depend on specific imaging findings, such as appendiceal dilatation or the presence of appendicoliths 3.

Treatment Options for Acute Appendicitis in Pregnant Patients

• The management of acute appendicitis in pregnancy can involve either surgical intervention or conservative management with antibiotics 4.
• A retrospective study published in the Turkish Journal of Trauma and Emergency Surgery found that early surgical intervention was performed in 20 pregnant patients with acute appendicitis, with no fetal or maternal morbidity or mortality reported 4.
• However, another study published in the Journal of Gastrointestinal Surgery suggested that antibiotic treatment alone can be effective in managing acute appendicitis, although it may be associated with a higher risk of recurrent appendicitis 5.

Antibiotic Therapy for Acute Appendicitis

• Antibiotic therapy has been proposed as an alternative to immediate appendectomy for acute appendicitis, with some studies suggesting that it can reduce the risk of immediate complications, but may be associated with a higher risk of subsequent failures 6.
• A systematic review published in Prescrire International found that antibiotic therapy was effective in managing uncomplicated acute appendicitis in adults, but the optimal duration and type of antibiotic treatment remain unclear 6.
• The use of broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with cephalosporins or fluoroquinolones with metronidazole, has been suggested as a potential treatment option for acute appendicitis 3.