Antimicrobial Therapy for Children with Appendicitis

Publication Date: March 1, 2008

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

...sment and Diagnosis...

...ings for appendicitis obtained from the history, p...


Table 1. The Alvarado Score (Mnemonic for the diagnostic score of acute appendicitis: MANTRELS)

...The Alvarado Score (Mnemonic for the diag...

...uspected Appendicitis


Imaging

...maging

...the patient’s age, history and p...


...is the initial imaging modality of choice for susp...


...ould undergo diagnostic imaging. Thos...

If these studies do not define the pathology pre...


...all children (particularly those under...


...tients with negative imaging studies for...


...nts with suspected appendicitis that can nei...


Antimicrobial Therapy

...imicrobial The...

...timicrobial therapy should be administered to al...


...timicrobial therapy includes agents effective...


...apy should be started when the diagnosis of...


...pendicitis without evidence of perforation,...


...ients with suspected appendicitis whose diagnos...


Microbiology

...obiology...

...s may help define the presence of yeast. (...


...igher-risk patients, aerobic and anaerobic...


...nt appears clinically toxic or is severely...


...bility testing for Pseudomonas, Proteus, Acin...


...there is significant resistance (great...


Table 2. Initial Intravenous Adult and Child Doses of Antibiotics for Empiric Treatment of Complicated Intra-Abdominal Infections

.... Initial Intravenous Adult and Child Do...

Outpatient Antimicrobial Therapy

...utpatient Antimicrobial...

...en and adults whose signs and symp...


...ecovering from intra-abdominal infection, c...


...e and susceptibility testing identify or...


...r children, outpatient parenteral antibiotic ma...


For oral step-down therapy in childre...