Appendicitis Clinical Pathway — Inpatient

Delayed Appendectomy in Patients with Perforated Appendicitis with Abscess Non-operative Management of Acute Appendicitis

Patients who will be managed initially with non-operative protocol will be admitted to General Surgery.

Patients will remain NPO and receive IV antibiotics for at least 24 hours while VS and clinical exam are monitored.

Patients who worsen or fail to improve will undergo appendectomy.

Criteria for Non-operative Management of Acute Appendicitis
Inclusion Criteria	Age White blood cell count Pain Imaging	≥ 7 and ≤ 18 years ≤ 18,000 cells/µL ≤ 48 hours prior to receiving antibiotics US, MRI, or CT scan confirms acute appendicitis with: Appendiceal diameter ≤1.1 cm (normal ≤ 0.6 cm) No phlegmon, abscess or appendicolith
Exclusion Criteria	Diffuse peritonitis History of chronic or intermittent abdominal pain Family unwilling or unable to follow-up Communication difficulties (e.g. severe developmental delay) Sepsis Immunocompromised

Non-operative Clinical Care

Fluids, Nutrition

IVF
NPO for 12 hours and until improving

Observation Serial PE

No improvement in 24 hours or clinical worsening
Crossover to Surgery

IV Antibiotics

IV Regimen
Healthy Children
Immunocompromised or hospitalized

Ceftriaxone + Metronidazole
Piperacillin-tazobactam

Transition to PO Antibiotics

PO Regimen
Ciprofloxacin + Metronidazole
Note
An alternative drug for children who do not tolerate metronidazole is difficult to identify.
Amoxicillin/clavulanate may be adequate, but an IV regimen might need to be considered due to high rates of amoxicillin/clavulanate resistance among E. coli at CHOP.
Consider ID Consultation

Patients Clinically Improving on IV Antibiotics

Patients clinically improving, meeting Discharge Criteria Below
- Continue antibiotics for at least 24 hours
- Advance diet
- When tolerating regular diet
- Transition to PO antibiotics
- Discharge after tolerates 1^st dose of antibiotics to complete 14 days of antibiotics

DC Criteria

Minimum of 24 hours of IV antibiotics
Minimum of 24 hours inpatient observation
Tolerance of a regular diet and first dose of oral antibiotics
Absence of abdominal pain
Afebrile for 24 hours
Completion of patient, caretaker education of signs warranting repeat evaluation
- See discharge instructions

Criteria for Failure of Non-operative Management and Cross-over to Appendectomy
Family decides they wish to pursue appendectomy
Patients Worsening or Inadequate Clinical Improvement within 12 - 24 Hours	Clinically Worsening Tenderness spreading to at least 1 additional quadrant compared to presentation or tenderness becoming generalized Signs of sepsis (hypotension, altered mental status) Inadequate Improvement Tenderness on exam similar to presentation Pain, no improvement or continued pain scores of ≥ 4 on a scale from 1-10 Nausea or emesis Failing to tolerate PO Temperature > 101, elevated heart rate

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.