Appendicitis medical therapy: Difference between revisions

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Latest revision as of 20:27, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamed Moubarak, M.D. [2] Faizan Sheraz, M.D. [3]

Overview

The mainstay of management for appendicitis is surgery. Antimicrobial therapy is administered for patients with complicated, perforated appendicitis and those who are not managed surgically.

Medical Therapy

The mainstay of therapy of appendicitis with or without rupture is surgery. Patients should be routinely resuscitated with intravenous fluids, especially with those with suspected sepsis.^[1]

Nonsurgical treatment is not recommended and should be reserved for cases where:^[2]

Surgery is not available
Patient is not a candidate for surgical intervention
The diagnosis is uncertain

Antibiotic Therapy

Once the patient is diagnosed with appendicitis, antibiotics should be started immediately. Preoperative antibiotics have been associated with lower rates of wound and intra-abdominal infections.^[1] The duration of post-operative treatment with intravenous antibiotics ranges from 5 to 10 days, until fever resolves, white blood cell count normalizes, and bowel function returns.

Antimicrobial Regimens

1. Community-acquired infection in adults ^[1]

1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):

1.1.1. Single agent:

Preferred regimen (1): Cefoxitin 2 g IV q6h
Preferred regimen (2): Ertapenem 1 g IV q24h
Preferred regimen (3): Moxifloxacin 400 mg IV q24h
Preferred regimen (4): Tigecycline 100 mg initial dose, THEN 50 mg IV q12h
Preferred regimen (5): Ticarcillin-clavulanic acid 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection

1.1.2. Combination:

Preferred regimen (1): Cefazolin 1–2 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (2): Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (3): Ceftriaxone 1–2 g IV q12–24 h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (4): Cefotaxime 1–2 g IV q6–8 h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h

1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):

1.2.1. Single agent:

Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h
Preferred regimen (2): Meropenem 1 g IV q8h
Preferred regimen (3): Doripenem 500 mg IV q8h
Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h

1.2.2. Combination:

Preferred regimen (1): Cefepime 2 g q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (2): Ceftazidime 2 g q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (3): Ciprofloxacin 400 mg q12h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (4): Levofloxacin 750 mg q24h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

2. Health Care–Associated Complicated Intra-abdominal Infection ^[1]

2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg q8–12 h or 1500 mg q24h
Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (3): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Ceftazidime 2 g IV q8h AND Metronidazole 500 mg IV every 8–12 h or 1500 mg q24h
Preferred regimen (4): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg q8–12 h or 1500 mg q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h
Preferred regimen (6): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Cefepime 2 g IV q8–12 h AND Metronidazole 500 mg IV q8–12 h or 1500 mg q24h

2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:

Preferred regimen (1): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (2): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (3): Meropenem 1 g IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h
Preferred regimen (7): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Gentamicin 5–7 mg/kg IV q24h
Preferred regimen (8): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Tobramycin 5–7 mg/kg IV q24h
Preferred regimen (9): Doripenem 500 mg IV q8h AND Piperacillin-tazobactam 3.375 g IV q6h AND Amikacin 15–20 mg/kg IV q24h

2.4.Methicillin-resistant Staphylococcus aureus (MRSA):

Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12 h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

3. Community-acquired infection in pediatric patients

3.1. Single agent:

Preferred regimen (1): Ertapenem 3 months to 12 years 15 mg/kg bid (not to exceed 1 g/day) Every 12 h, older than 13 years 1 g/day Every 24 h OR
Preferred regimen (2): Meropenem 60 mg/kg/day q8h
Preferred regimen (3): Imipenem-cilastatin 60–100 mg/kg/day IV q6h
Preferred regimen (4): Ticarcillin-clavulanate 200–300 mg/kg/day IV of Ticarcillin component q4–6 h
Preferred regimen (5): Piperacillin-tazobactam 200–300 mg/kg/day IV of Piperacillin component q6–8 h

3.2.Combination:

Preferred regimen (1): Ceftriaxone 50–75 mg/kg/day q12–24 h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen (2): Cefotaxime 150–200 mg/kg/day q6–8 h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen (3): Cefepime 100 mg/kg/day q12h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen (4): Ceftazidime 150 mg/kg/day q8 h, AND Metronidazole 30–40 mg/kg/day q8h
Preferred regimen (5): Gentamicin 3–7.5 mg/kg/day q2–4 h, AND Metronidazole 30–40 mg/kg/day q8h ± Ampicillin 200 mg/kg/day q6h
Preferred regimen (6): Gentamicin 3–7.5 mg/kg/day q2–4 h, AND Clindamycin 20–40 mg/kg/day q6–8 h ± Ampicillin 200 mg/kg/day q6h
Preferred regimen (7): Tobramycin 3.0–7.5 mg/kg/day q8–24 h, AND Metronidazole 30–40 mg/kg/day q8h ± Ampicillin 200 mg/kg/day q6h
Preferred regimen (8): Tobramycin 3.0–7.5 mg/kg/day q8–24 h, AND Clindamycin 20–40 mg/kg/day q6–8 h ± Ampicillin 200 mg/kg/day q6h
Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.
↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.

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[pmid20034345-1] 1.0 ^1.1 ^1.2 ^1.3 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.

[2] Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.

[1]

[2]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Appendicitis}}
-{{CMG}}
+{{CMG}}; {{AE}} {{MM}} {{Faizan}}
 ==Overview==
-In combination with surgery, [[antibiotics]] are given intravenously to help kill [[bacteria]] and thus reduce the spread of [[infection]] in the [[abdomen]] and postoperative complications in the abdomen or wound.
+The mainstay of management for appendicitis is surgery. Antimicrobial therapy is administered for patients with complicated, perforated appendicitis and those who are not managed surgically.
-==Appendicitis Medical Therapy==
+==Medical Therapy==
+The mainstay of therapy of appendicitis with or without rupture is surgery.  Patients should be routinely resuscitated with intravenous fluids, especially with those with suspected sepsis.<ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
-Acute appendicitis is primary treated with surgery, either without rupture or with perforation and secondary peritonitis. Pre-operative antibiotics used in acute appendicitis include [[cefuroxime]] and [[metronidazole]].  Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations.
+Nonsurgical treatment is not recommended and should be reserved for cases where:<ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages =  }}</ref>
+*Surgery is not available
+*Patient is not a candidate for surgical intervention
+*The diagnosis is uncertain
+===Antibiotic Therapy===
+Once the patient is diagnosed with appendicitis, antibiotics should be started immediately. Preoperative antibiotics have been associated with lower rates of wound and intra-abdominal infections.<ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref> The duration of post-operative treatment with intravenous antibiotics ranges from 5 to 10 days, until fever resolves, white blood cell count normalizes, and bowel function returns.
+====Antimicrobial Regimens====
+*'''1. Community-acquired infection in adults''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
+:*'''1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):'''
+::*'''1.1.1. Single agent:'''
+:::*Preferred regimen (1): [[Cefoxitin]] 2 g IV q6h
+:::*Preferred regimen (2): [[Ertapenem]] 1 g IV q24h
+:::*Preferred regimen (3): [[Moxifloxacin]] 400 mg IV q24h
+:::*Preferred regimen (4): [[Tigecycline]] 100 mg initial dose, {{then}} 50 mg IV q12h
+:::*Preferred regimen (5): [[Ticarcillin]]-[[clavulanic acid]] 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection
+::*'''1.1.2. Combination:'''
+:::*Preferred regimen (1): [[Cefazolin]] 1–2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (2): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q12–24 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (4): [[Cefotaxime]] 1–2 g IV  q6–8 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (5): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:::*Preferred regimen (6): [[Levofloxacin]] 750 mg IV  q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
+:*'''1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):'''
+::*'''1.2.1. Single agent:'''
+:::*Preferred regimen (1): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h
+:::*Preferred regimen (2): [[Meropenem]] 1 g IV q8h
+:::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h
+:::*Preferred regimen (4): [[Piperacillin-tazobactam]] 3.375 g IV q6h
+::*'''1.2.2. Combination:'''
+:::*Preferred regimen (1): [[Cefepime]] 2 g  q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Preferred regimen (2): [[Ceftazidime]] 2 g q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Preferred regimen (3): [[Ciprofloxacin]] 400 mg q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Preferred regimen (4): [[Levofloxacin]]  750 mg q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:::*Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
+*'''2. Health Care–Associated Complicated Intra-abdominal Infection''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345  }} </ref>
+:*'''2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other  multidrug resistant gram-negative bacilli:'''
+::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
+::*Preferred regimen (2): [[Imipenem-cilastatin]] 500 mg IV 6 h {{or}} 1 g  q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV every 8–12 h or 1500 mg q24h
+::*Preferred regimen (4): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
+::*Preferred regimen (5): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+::*Preferred regimen (6): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
+:*'''2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:'''
+::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+::*Preferred regimen (4): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (5): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (6): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+:*'''2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:'''
+::*Preferred regimen (1): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (2): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (3): [[Meropenem]]  1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+::*Preferred regimen (4): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (5): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (6): [[Imipenem-cilastatin]] 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
+::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
+::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g  IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
-Nonsurgical treatment may be used if:
+:*'''2.4.Methicillin-resistant Staphylococcus aureus (MRSA):'''
-*Surgery is not available
+::*Preferred regimen: [[Vancomycin]] 15–20 mg/kg IV q8–12 h
-*If a person is not well enough to undergo [[surgery]]
+::*Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
-*If the diagnosis is unclear
-The duration of post-operative treatment with intravenous antibiotics ranges from 5 to 10 days, until fever resolves, white blood cell count normalizes, and bowel function returns.
-Some research suggests that appendicitis can get better without [[surgery]]. Nonsurgical treatment includes [[antibiotic]]s to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the [[gastrointestinal tract]].<ref name="pmid12592478">{{cite journal| author=Kirshenbaum M, Mishra V, Kuo D, Kaplan G| title=Resolving appendicitis: role of CT. | journal=Abdom Imaging | year= 2003 | volume= 28 | issue= 2 | pages= 276-9 | pmid=12592478 | doi=10.1007/s00261-002-0025-3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12592478  }} </ref><ref name="pmid10796906">{{cite journal| author=Cobben LP, de Van Otterloo AM, Puylaert JB| title=Spontaneously resolving appendicitis: frequency and natural history in 60 patients. | journal=Radiology | year= 2000 | volume= 215 | issue= 2 | pages= 349-52 | pmid=10796906 | doi=10.1148/radiology.215.2.r00ma08349 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10796906  }} </ref>
+*'''3. Community-acquired infection in pediatric patients'''
+:*'''3.1. Single agent:'''
+::*Preferred regimen (1): [[Ertapenem]] 3 months to 12 years 15 mg/kg bid (not to exceed 1 g/day) Every 12 h, older than 13 years 1 g/day Every 24 h {{or}}
+::*Preferred regimen (2): [[Meropenem]] 60 mg/kg/day q8h
+::*Preferred regimen (3): [[Imipenem-cilastatin]] 60–100 mg/kg/day IV q6h
+::*Preferred regimen (4): [[Ticarcillin-clavulanate]] 200–300 mg/kg/day IV of [[Ticarcillin]] component q4–6 h
+::*Preferred regimen (5): [[Piperacillin-tazobactam]] 200–300 mg/kg/day IV of [[Piperacillin]] component q6–8 h
+:*'''3.2.Combination:'''
+::*Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg/day q12–24 h, {{and}} [[Metronidazole]] 30–40 mg/kg/day q8h
+::*Preferred regimen (2): [[Cefotaxime]] 150–200 mg/kg/day q6–8 h, {{and}} [[Metronidazole]] 30–40 mg/kg/day q8h
+::*Preferred regimen (3): [[Cefepime]] 100 mg/kg/day q12h, {{and}} [[Metronidazole]] 30–40 mg/kg/day q8h
+::*Preferred regimen (4): [[Ceftazidime]] 150 mg/kg/day q8 h, {{and}} [[Metronidazole]] 30–40 mg/kg/day q8h
+::*Preferred regimen (5): [[Gentamicin]] 3–7.5 mg/kg/day q2–4 h, {{and}} [[Metronidazole]] 30–40 mg/kg/day q8h {{withorwithout}} [[Ampicillin]] 200 mg/kg/day q6h
+::*Preferred regimen (6): [[Gentamicin]] 3–7.5 mg/kg/day q2–4 h, {{and}} [[Clindamycin]] 20–40 mg/kg/day q6–8 h {{withorwithout}} [[Ampicillin]] 200 mg/kg/day q6h
+::*Preferred regimen (7): [[Tobramycin]] 3.0–7.5 mg/kg/day q8–24 h, {{and}} [[Metronidazole]] 30–40 mg/kg/day q8h {{withorwithout}} [[Ampicillin]] 200 mg/kg/day q6h
+::*Preferred regimen (8): [[Tobramycin]] 3.0–7.5 mg/kg/day q8–24 h, {{and}} [[Clindamycin]] 20–40 mg/kg/day q6–8 h {{withorwithout}} [[Ampicillin]] 200 mg/kg/day q6h
+::*Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
 ==References==
-{{reflist|2}}
+{{Reflist|2}}
 {{WH}}
 {{WS}}
-[[Category:Primary care]]
-[[Category:emergency medicine]]
+[[Category:Emergency medicine]]
-[[Category:Inflammations]]
+[[Category:Surgery]]
-[[Category:Medical emergencies]]
-[[Category:General surgery]]
 [[Category:Gastroenterology]]
-[[Category:Disease]]
-[[Category:Needs content]]