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

...ent and Diagnosis...

...Key findings for appendicitis obtain...


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

...lvarado Score (Mnemonic for the diagnosti...

...ed Appendicitis...


Imaging

...aging

...d upon the patient’s age, history...


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


...males should undergo diagnostic imaging. Those...

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


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


For patients with negative imaging st...


...h suspected appendicitis that can neit...


Antimicrobial Therapy

...imicrobial The...

...timicrobial therapy should be administered...


...riate antimicrobial therapy includes age...


...h therapy should be started when the dia...


...itis without evidence of perforatio...


...ients with suspected appendicitis whose diag...


Microbiology

...crobiolo...

...ram stains may help define the presence of yeast...


...higher-risk patients, aerobic and anaer...


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


...ity testing for Pseudomonas, Proteus...


...is significant resistance (greater than 10...


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

...nitial Intravenous Adult and Child Doses of Antib...

Outpatient Antimicrobial Therapy

...atient Antimicrobial Th...

...ildren and adults whose signs and sympt...


...covering from intra-abdominal infection, com...


...f culture and susceptibility testing...


...tpatient parenteral antibiotic manag...


...r oral step-down therapy in children, int...