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 1st 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