[size=6]You are asked to assess a 12-year-old child with appendicitis. The appendix is 10mm in diameter on CT with no fecalith. There is a low-grade fever and the WBC = 13,000/uL. After 12 hours of IV ceftriaxone and metronidazole the pain has improved. The patient and their parents have expressed a strong desire to avoid surgical intervention. They confirm adequate access to follow up care. What of the following is the most appropriate management?

 

a IV antibiotics for 48 hours then discharge home on 7 days of PO cefdinir/metronidazole

 

b Discharge on PO cipro/metronidazole for 14 days

 

c IV antibiotics until afebrile and a normal WBC then discharge home with no further antibiotics

 

d Discharge on PO cefdinir/metronidazole for 7 days[/size]

C

C

A..

correct answer

d Discharge on PO cefdinir/metronidazole for 7 days

 

This patient had improvement in their symptoms with 12 hours of IV antibiotics, a low-grade fever and no fecalith, so they satisfy the criteria for published non-operative management (NOM) protocols for appendicitis. Because the family wishes to avoid appendectomy, it is reasonable to consider NOM, although its pros and cons should be carefully discussed with them. Studies of NOM over the last 10 years have demonstrated mixed results, with a recent noninferiority trial reporting 1-year failure of about 34%.

 

However, there are data that suggest a reduction in disability days, certain metrics of psychological stress, and initial healthcare costs with NOM. In most cases, patients should be admitted for at least 12 to 24 hours to receive the first dose of antibiotics parenterally and to monitor for treatment failure then discharged home to complete 7 to 10 total days of antibiotic with an oral regimen. In certain low-risk cases, patients may be discharged home from the emergency department. Regarding oral antibiotic therapy, several studies suggest high rates of community resistance of E. coli to amoxicillin-clavulanate (not specifically, however, in the context of pediatric appendicitis), resulting in suboptimal outcomes in some situations. Selection of antimicrobial agents should, therefore, be informed by institutional/regional antibiograms when available, and target mixed enteric flora.