Appendicitis — General Antibiotic Recommendations — Clinical Pathway: Inpatient

General Antibiotic Recommendations

Antibiotic Recommendations for Appendicitis

	Recommended Antibiotic	Second line for cephalosporin and/or severe penicillin allergy¹	Comments
Appendicitis (including acute non-perforated, acute perforated, post-operative abscess, non-operative management of perforated appendicitis with abscess)	Ceftriaxone Infants, Children, Adolescents, and Adults: 75 mg/kg/day IV every 24 hours Max dose 2000 mg AND Metronidazole Infants PMA > 44 weeks Children, Adolescents, and Adults: 7.5 mg/kg/dose IV every 6 hours or 10 mg/kg/dose IV every 8 hours Max dose: 2000 mg/day	Ciprofloxacin Children, Adolescents, and Adults: 10 mg/kg/dose IV every 8 hours Max dose: 400 mg/dose, 1,200 mg/day AND Metronidazole Infants PMA > 44 weeks Children, Adolescents, and Adults: 7.5 mg/kg/dose every 6 hours or 10 mg/kg/dose every 8 hours Max dose: 2000 mg/day	Patients discharged on oral antibiotics: Ciprofloxacin Children, Adolescents, and Adults: 20 mg/kg/dose PO BID Max dose: 750 mg/dose, 1500 mg/day AND Metronidazole Infants PMA > 44 weeks Children, Adolescents, and Adults: 7.5 mg/kg/dose PO QID Max dose: 500 mg/dose For perforated appendicitis patients receiving IV ceftriaxone/metronidazole who are still febrile and symptomatic on POD 3: It is reasonable to consider switching to a different antibiotic regimen such as piperacillin/tazobactam Consider ID Consult
Recent Hospitalization > 4 Days/Immunocompromised/Very Ill	Consult Infectious Disease Piperacillin/Tazobactam ≥ 2-9 months: 80 mg piperacillin/kg/dose every 8 hours Infants ≥ 9 months, Children, Adolescents ≤ 40 kg: 100 mg piperacillin/kg/dose every 8 hours Max dose: 3000 mg piperacillin/day Children, Adolescents > 40 kg: 3000 mg piperacillin every 6 hours

Please see the CHOP Formulary monograph for complete information.

Footnotes

Severe penicillin allergy includes any of the following: anaphylaxis, angioedema, cardiac arrest, respiratory distress, severe cutaneous reaction (for example, Stevens Johnson syndrome, erythema multiforme, DRESS and TEN). Patients who experience hives with penicillin can receive cephalosporins as recommended; however, if piperacillin-tazobactam is recommended, second line antibiotics should be used. All other reactions considered non-severe and should receive the recommended antibiotic.
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.

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