Outpatient Antimicrobial Therapy
ÎFor children and adults whose signs and symptoms of infection are resolved, no further antibiotic therapy is required (B-III).
ÎFor adults recovering from intra-abdominal infection, completion of the antimicrobial course with oral forms of moxifloxacin, ciprofloxacin plus metronidazole, levofloxacin plus metronidazole, an oral cephalosporin with metronidazole, or amoxicillin/clavulanic acid is acceptable in patients able to tolerate an oral diet and where susceptibility studies do not demonstrate resistance (B-II). Antibiotic therapy beyond 4-7 days is rarely indicated for perforated appendicitis.
ÎIf culture and susceptibility testing identify organisms susceptible only to intravenous therapy, such therapy may be given outside of the hospital (B-III).
ÎFor children, outpatient parenteral antibiotic management may be considered when subsequent drainage procedures are not likely to be required, but symptoms of ongoing intra-abdominal inflammation persist in the context of decreasing fever, controlled pain, ability to tolerate oral fluids and ability to ambulate (B-II).
ÎFor oral step-down therapy in children, intra-abdominal cultures at the time of the drainage procedure are recommended to allow for the use of the most narrow spectrum, best tolerated and safest oral therapy. A second or third generation cephalosporin in combination with metronidazole, or amoxicillin/clavulanate may be options if the isolated organisms are susceptible to these agents. Fluoroquinolones such as ciprofloxacin or levofloxacin may be used to treat susceptible Pseudomonas, Enterobacter, Serratia and Citrobacter species (B-III). If ciprofloxacin or levofloxacin is used, metronidazole should be added.
Table 3. Antibiotics Appropriate for Use in Appendicitis Children (< 16)
Adults
Single agent Ertapenem Meropenem Imipenem/cilastatin Ticarcillin/clavulanate Piperacillin/tazobactam
Combination regimen
Ceſtriaxone, cefotaxime, cefepime, or ceſtazidime, each in combination with metronidazole Gentamicin or tobramycin, each in combination with metronidazole or clindamycin, and with or without ampicillin
Cefoxitin Ertapenem Moxifloxacin Tigecyclinea Ticarcillin/clavulanic acid
Cefazolin, cefuroxime, ceſtriaxone, cefotaxime, ciprofloxacin, or levofloxacin, each in combination with metronidazole
a Although patients with appendicitis rarely have physiologically severe infection, a 0.6% increase in mortality has been found in a pooled analysis of all patients treated with tigecycline in clinical trials.
