Appendicitis medical therapy
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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 therapy for appendicitis is surgery combined with antimicrobial therapy administered intravenously. Empiric antimicrobial therapy depends on the cause (community-acquired or healthcare-associated complicated intraabdominal infection) and the severity of the disease.
Appendicitis Medical Therapy
Acute appendicitis is primary treated with surgery, either without rupture or with perforation and secondary peritonitis. Patients should be resuscitated with intravenous fluids, especially with septic shock.[1]
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.[2]
As blood cultures do not provide any additional clinical information for community-acquired intra-abdominal infection, they are not routinely recommended for such patients.[1]
Nonsurgical treatment may be used if:[3]
- Surgery is not available
- If a person is not well enough to undergo surgery
- 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 antibiotics 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.[4][5]
Timing of Antibiotic Therapy
Once the patient is diagnosed with appendicitis, antibiotics should be started immediately.[1]
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 1.4 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.
- ↑ 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.
- ↑ Kirshenbaum M, Mishra V, Kuo D, Kaplan G (2003). "Resolving appendicitis: role of CT". Abdom Imaging. 28 (2): 276–9. doi:10.1007/s00261-002-0025-3. PMID 12592478.
- ↑ Cobben LP, de Van Otterloo AM, Puylaert JB (2000). "Spontaneously resolving appendicitis: frequency and natural history in 60 patients". Radiology. 215 (2): 349–52. doi:10.1148/radiology.215.2.r00ma08349. PMID 10796906.