What is the management approach for acute appendicitis (inflammation of the appendix)?

From the Guidelines

The management of acute appendicitis typically involves prompt surgical intervention through appendectomy, which remains the standard of care, as stated in the most recent guidelines from 2023 1. Once diagnosed, patients should be started on intravenous antibiotics (such as a combination of cefazolin 1-2g IV and metronidazole 500mg IV, or piperacillin-tazobactam 3.375g IV every 6 hours) and prepared for surgery. Patients should be kept nil by mouth, receive intravenous fluids for hydration, and receive appropriate pain management with medications like morphine 0.1mg/kg IV or hydromorphone 0.015mg/kg IV. Laparoscopic appendectomy is generally preferred over open appendectomy due to faster recovery, shorter hospital stays, and fewer wound complications, as supported by the 2020 update of the WSES Jerusalem guidelines 1. Some key points to consider in the management of acute appendicitis include:

• The role of diagnostic imaging, such as ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI), in the diagnosis of acute appendicitis 1
• The use of clinical scoring systems to aid in predicting the risk of acute appendicitis 1
• The importance of prompt surgical intervention to prevent complications such as perforation, peritonitis, and sepsis 1
• The consideration of non-operative management with antibiotics alone in select cases of uncomplicated appendicitis, although this approach carries a 25-30% risk of recurrence within a year 1 Postoperatively, patients typically resume oral intake as tolerated, continue antibiotics for 24 hours in uncomplicated cases or 3-7 days in complicated cases (perforation or abscess), and are discharged when they can tolerate oral intake, have adequate pain control, and show no signs of complications. Surgical intervention is crucial because untreated appendicitis can progress to perforation, leading to peritonitis, sepsis, and significantly increased morbidity and mortality, as highlighted in the 2020 update of the WSES Jerusalem guidelines 1. In certain cases, such as patients with major comorbidities unfit for surgery and peri-appendiceal abscess, percutaneous image-guided drainage associated with antibiotic therapy may be considered, as stated in the 2023 guidelines 1. Overall, the management of acute appendicitis requires a comprehensive approach that takes into account the patient's individual needs and circumstances, as well as the latest evidence-based guidelines.

From the FDA Drug Label

1. 2 Complicated Intra-abdominal Infections (Adult and Pediatric Patients) Meropenem for injection is indicated for the treatment of complicated appendicitis and peritonitis caused by viridans group streptococci, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Bacteroides fragilis, B. thetaiotaomicron,and Peptostreptococcusspecies. The management approach after diagnosing a patient with acute appendicitis is to treat the infection with an antibiotic such as meropenem. The recommended dose is 1 gram given every 8 hours for intra-abdominal infections 2.

• Key points:
  • Meropenem is indicated for the treatment of complicated appendicitis.
  • The dose should be adjusted based on the patient's renal function.
  • Local epidemiology and susceptibility patterns should be considered in selecting or modifying antibacterial therapy 2.

From the Research

Management Approach

The management approach for acute appendicitis can be divided into two main categories: uncomplicated and complicated disease.

• Uncomplicated acute appendicitis can be managed with antibiotics alone, with a success rate of approximately 70% of patients 3.
• Complicated acute appendicitis, on the other hand, requires timely surgical intervention 4.

Treatment Options

Treatment options for acute appendicitis include:

• Antibiotics: broad-spectrum antibiotics such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole can be used to treat uncomplicated acute appendicitis 3.
• Appendectomy: laparoscopic appendectomy remains the most common treatment for acute appendicitis, especially for complicated cases 3.
• Percutaneous drainage: patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management 4.

Patient Populations

Certain patient populations require special consideration:

• Pregnant patients: should undergo timely surgical intervention to decrease the risk of complications 4.
• Immunocompromised patients: should also undergo timely surgical intervention to decrease the risk of complications 4.
• Unfit patients: may be considered for an antibiotics-first approach, but perioperative risk assessment and patient preferences should be taken into account 3.

Imaging and Diagnosis

Imaging modalities such as ultrasound, computer tomography, and magnetic resonance imaging can be used to make the diagnosis of acute appendicitis, with each study having its own sensitivity and specificity 4.

• CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with a higher risk of treatment failure with an antibiotics-first approach 3.