Management of nonperforated appendicitis in adults

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Management of nonperforated appendicitis in adults

Inset1:Comparisonofantibioticsversusappendectomyfor
NonperforatedappendicitisbasedonCT* nonperforatedappendicitis

Doesthepatienthaveanyofthefollowing?
•Diffuseperitonitis
•Hemodynamicinstability
•Severesepsis
•Pregnancy
*Ahistoryofranatoryboweldisease
Yes
Discusswithpatienttheadvantagesand
disadvantagesofantibiotictherapyversusappendectomy
(refertoInset1formajorpoints)
Informpatientthatthosewithappendicolithare
morelikelytofailnonoperativemanagementand
Tase2Sateeatibiticchoicesfornonoperativemanagementof
requireappendectomy
Decisionfornonoperativemanagement Decisionforsurgery
ObservationandintravenousantibioticsA
for1to3daysinhospitalorED°
Clinicalimprovement Failuretoimprove
Antibiotics Appendectomy
Advantages
•Shorte
durato
odisabley
comparedwithsurgery
*Apeapere/montneverrecurs
•Lowerincidenceofsubsequent
•Notassociatedwithanincreased hospitalizationthannonoperative
riskofappendixrupturing management
comparedwithsurgery
Disadvantages •10to20%failurerateat30day=5 •Requiressurgeryandanesthesia
•30to40%recurrencerateat1yearS •Longerdurationofdisability
•40to50%recurrencerateat5years$ requiredtorecoverfromsurgery
•Smallriskofmissedneoplasm
(mostlyinolderpatients)
Intravenousantibiotics(for1to3daysuntildinicalimprovement):
•Colisten5monedayBUSmetronial500mwerehours
Oralantibiotics(tocomplete7to10days,inclusiveofintravenousantibioticdays):
•Cefdinir300mgtwicedaily
•Ciprofloxacin500mgtwicedailyorlevofloxacin750mgdailyPLUS
metronidazole500mgevery8hours
•Amoxicillin-clavulanate875mgtwicedaily*

Dischargehomeonoralantibiotics Appendectomy
tocompletea7-to10-daycourse

CT: computed tomography; ED: emergency department.

* Nonperforated appendicitis, also referred to as simple appendicitis or uncomplicated appendicitis, refers to acute appendicitis that presents without
CT signs of perforation (eg, inflammatory mass, phlegmon, or abscess).

¶ Nonoperative management has not been sufficiently studied in these patients, as they have been excluded from the trials.

Δ Antibiotic choices are not standardized. Refer to Inset 2 for sample choices. Refer to UpToDate content on the management of appendicitis for other
appropriate antibiotic regimens.

◊ Antibiotic response may be delayed in patients who are 45 years of age or older; in those who have appendicoliths, extraluminal fluid or air, fever, or
elevated inflammatory markers; and in those who have had symptoms for more than 48 hours, all of which are associated with appendiceal abscess. A
longer period of observation and intravenous antibiotics may be required for these patients.

§ The lower percentage has been reported by trials excluding patients with appendicolith; the higher percentage has been reported by trials including
patients with appendicolith.

¥ These are sample choices for low- to moderate-risk community-acquired infections. For the full complement of suitable regimens, refer to the
appropriate UpToDate content on management of appendicitis. Doses shown are for patients with normal kidney function; some agents require
adjustment for kidney impairment; refer to drug monograph(s) included within UpToDate.

‡ Amoxicillin-clavulanate is a reasonable option if the community rate of Escherichia coli resistance to the agent is not >10%.

References:
1. Talan DA, Di Saverio S. Treatment of acute uncomplicated appendicitis. N Engl J Med 2021; 385:1116.
2. Talan DA, Saltzman DJ, DeUgarte DA, Moran GJ. Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review. J Trauma Acute
Care Surg 2019; 86:722.

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