Antimicrobial Therapy for Children with Appendicitis
Key Points
Key Points
- Appendicitis affects approximately 300,000 patients/year and consumes over 1 million hospital days in the US. Lifetime risk is 8.6% for males and 6.7% for females. In 2005, patients with abdominal pain composed 6.8%
of 115 million annual emergency department visits. - Appendicitis typically begins with luminal obstruction from inspissated fecal matter or lymphoid hyperplasia and progresses to perforation at a rate of approximately 5-10%/24 hours after the first 24 hours.
- In young, preverbal toddlers, the risk of perforation at the time of appendicitis diagnosis is high. In children younger than 4 years, appendiceal perforation occurs in the vast majority of cases, with rates reported as high as 80% to 100%. In contrast, appendicitis in children aged 10 to 17 years is more common, but the perforation rate is much lower (10%-20%).
- Appendicitis is generally diagnosed by a constellation of history and physical exam findings and limited laboratory evaluations.
- Diagnostic imaging is used to confirm the diagnosis in most women and children, and frequently in men as well.
- Most patients with acute appendicitis can be safely managed with laparoscopic or open appendectomy.
- Selected patients with periappendiceal abscess or phlegmon, and selected patients with acute, nonperforated appendicitis can be safely managed nonoperatively with antimicrobial therapy alone.
- Antimicrobial therapy is important in preventing the complications of acute appendicitis, including both surgical site infections and deep organ space abscesses.
- Antimicrobial therapy should be initiated preoperatively in all patients undergoing operative appendectomy. Antimicrobial therapy should be discontinued within 24 hours in patients with acute, nonperforated appendicitis.
- Patients with perforated appendicitis and patients being managed nonoperatively should receive antimicrobial therapy according to the general principles outlined for management of patients with complicated intra-abdominal infection.
Assessment and Diagnosis
...As...
...Key findings for appendicitis obtained from t...
Table 1. The Alvarado Score (Mnemonic for the diagnostic score of acute appendicitis: MANTRELS)
.... The Alvarado Score (Mnemonic for the diagnosti...
...ted Appendicitis...
Imaging
...Imag...
...patient’s age, history and physical findings, th...
...he initial imaging modality of choice for suspe...
...hould undergo diagnostic imaging. Those of childbe...
...dies do not define the pathology present,...
Imaging of all children (particularly those...
...patients with negative imaging stu...
...r patients with suspected appendicitis that can...
Antimicrobial Therapy
...Antimicrobial...
...crobial therapy should be administered...
...antimicrobial therapy includes agents effec...
Such therapy should be started when the di...
...appendicitis without evidence of perforation, ab...
...patients with suspected appendicitis whose...
Microbiology
...Mi...
...m stains may help define the presence of...
...k patients, aerobic and anaerobic cultures shou...
...appears clinically toxic or is severely i...
...y testing for Pseudomonas, Proteus, Acinetobacter,...
...s significant resistance (greater than 10-20%) o...
Table 2. Initial Intravenous Adult and Child Doses of Antibiotics for Empiric Treatment of Complicated Intra-Abdominal Infections
...Initial Intravenous Adult and Child Doses of Antib...
Outpatient Antimicrobial Therapy
...Outpatient Antimicr...
...or children and adults whose signs and symp...
...ering from intra-abdominal infection, co...
...f culture and susceptibility testin...
...hildren, outpatient parenteral antibio...
...al step-down therapy in children, intra-abdominal...