Pediatric Appendicitis Organism-Specific Therapy

Updated: Dec 07, 2017

Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Thomas E Herchline, MD more...

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Pediatric Appendicitis Organism-Specific Therapy

Sections Pediatric Appendicitis Organism-Specific Therapy
Organism-Specific Therapy
References

Organism-Specific Therapy

Organism-specific therapeutic regimens for appendicitis in children are outlined below, including those for anaerobic organisms (including Bacteroides fragilis, Clostridium species [spp], and Prevotella spp), aerobic gram-negative bacilli (including Escherichia coli, Klebsiella spp, and Proteus mirabilis), Pseudomonas aeruginosa,streptococci, enterococci, and mixtures of aerobes and anaerobes. Historically, extended spectrum antibiotics were used for complicated appendicitis.^{[1, 2, 3, 4, 5, 6, 7, 8, 9]}

A comprehensive retrospective study that included almost 25,000 children aged 3-18 years discharged from 2011-2013 from 23 freestanding children’s hospitals concluded that extended-spectrum antibiotics seem to offer no advantage over narrower-spectrum agents for children with surgically managed acute uncomplicated or complicated appendicitis.^[10] The authors suggest that this observation is consistent with the failure of pseudomonas or other highly resistant gram negative organisms to frequently play an etiologic role in the morbidity associated with complicated or uncomplicated acute appendicitis. Given the rising frequency of resistant organisms and the increased cost of the extended spectrum antibiotics, unless a specific organism has been identified, narrow spectrum should be used as empiric therapy.^{[11, 12, 13]}

Anaerobic organisms (including Bacteroides fragilis, Clostridium spp, Prevotella spp)

Recommendations are as follows:

Clindamycin 20-40 mg/kg/day IV divided q6-8h or
Metronidazole 30-40 mg/kg/day IV divided q8h or
Ampicillin-sulbactam 200 mg/kg/day (based on ampicillin component) IV/IM divided q6h or
Ticarcillin-clavulanate 200-300 mg/kg/day (based on ticarcillin component) IV divided q4-6h

Aerobic gram-negative bacilli (including Escherichia coli, Klebsiella spp, Proteus mirabilis)

Recommendations are as follows:

Aztreonam 90-120 mg/kg/day IV divided q6-8h or
Ampicillin 200 mg/kg/day IV divided q12h or
Cefoxitin 80-160 mg/kg/day IV divided q4-6h or
Cefotetan 40-80 mg/kg/day IV divided q12h or
Cefotaxime 150-200 mg/kg/day IV divided q6-8h or
Ceftriaxone 50-75 mg/kg IV q24h

Pseudomonas aeruginosa

Recommendations are as follows:

Aztreonam 90-120 mg/kg/day IV divided q6-8h or
Piperacillin-tazobactam 200-300 mg/kg/day (based on piperacillin component) IV divided q6h or
Imipenem-cilastin 60-100 mg/kg/day IV divided q6h or
Meropenem 60 mg/kg/day IV divided q8h

Streptococci and enterococci

Recommendations are as follows:

Ampicillin-sulbactam 200 mg/kg/day (based on ampicillin component) IV/IM divided q6h or
Ticarcillin-clavulanate 200-300 mg/kg/day (based on ticarcillin component) IV divided q4-6h or
Piperacillin-tazobactam 200-300 mg/kg/day (based on piperacillin component) IV divided q6-8h or
Imipenem-cilastin 60-100 mg/kg/day IV divided q6h or
Meropenem 60 mg/kg/day IV divided q8h

Mixtures of aerobes and anaerobes

Recommendations are as follows:

Cefoxitin 80-160 mg/kg/day IV divided q4-6h or
Cefotetan 40-80 mg/kg/day IV divided q12h or
Ticarcillin-clavulanate 200-300 mg/kg/day (based on ticarcillin component) IV divided q4-6h or
Piperacillin-tazobactam 200-300 mg/kg/day (based on piperacillin component) IV divided q6-8h or
Ampicillin-sulbactam 200 mg/kg/day (based on ampicillin component) IV/IM divided q6h or
Imipenem-cilastin 60-100 mg/kg/day IV divided q6h or
Meropenem 60 mg/kg/day IV divided q8h

Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE. Does this child have appendicitis?. JAMA. 2007 Jul 25. 298 (4):438-51. [QxMD MEDLINE Link].
Hernanz-Schulman M. CT and US in the diagnosis of appendicitis: an argument for CT. Radiology. 2010 Apr. 255 (1):3-7. [QxMD MEDLINE Link].
Katz MS, Freitas MS, Tucker JR, Click P. Appendicitis. Medscape Reference. Available at http://emedicine.medscape.com/article/926795-overview. January 9, 2009;
Kharbanda AB, Taylor GA, Fishman SJ, Bachur RG. A clinical decision rule to identify children at low risk for appendicitis. Pediatrics. 2005 Sep. 116 (3):709-16. [QxMD MEDLINE Link].
Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15. 50 (2):133-64. [QxMD MEDLINE Link].
Tsao K, St Peter SD, Valusek PA, Spilde TL, Keckler SJ, Nair A, et al. Management of pediatric acute appendicitis in the computed tomographic era. J Surg Res. 2008 Jun 15. 147 (2):221-4. [QxMD MEDLINE Link].
Hartwich J, Luks FI, Watson-Smith D, Kurkchubasche AG, Muratore CS, Wills HE, et al. Nonoperative treatment of acute appendicitis in children: A feasibility study. J Pediatr Surg. 2015 Oct 23. [QxMD MEDLINE Link].
Patel A, Mao KR, McNeil JC, Kaplan SL, Vallejo JG. Fever and Reversible Laboratory Abnormalities Associated with Prolonged Use of Piperacillin-Tazobactam in Children. Pediatr Infect Dis J. 2015 Aug. 34 (8):849-50. [QxMD MEDLINE Link].
Fallon SC, Hassan SF, Larimer EL, Rodriguez JR, Brandt ML, Wesson DE, et al. Modification of an evidence-based protocol for advanced appendicitis in children. J Surg Res. 2013 Nov. 185 (1):273-7. [QxMD MEDLINE Link].
Kronman MP, Oron AP, Ross RK, et al. Extended-Versus Narrower-Spectrum Antibiotics for Appendicitis. Pediatrics. June 2016. 138(1):[QxMD MEDLINE Link].
[Guideline] Committee on Infectious Diseases 2012-2015. Non-Group A or B Strep. & Enterococcal Inf, E. coli and Other Gram-Negative Bacilli, Bacteroides and Prevotella Inf., Clostridial Inf., Antimicrobial Resistance and Stewardship: Appropriate and Judicious Use,Tables of Antibacterial Drug Dosages. Kimberlin DW, Brady MT, Jackson MA, Long SS. Red Book 2015 Report of the Committee on Infectious Diseases. 30th Edition. IL: American Academy of Pediatrics; 2015. p881-895,p965-969,p961,p959,p258-259,p298-301,p340-343, p750-753,.
Chan KW, Lee KH, Mou JW, Cheung ST, Sihoe JD, Tam YH. Evidence-based adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance. Pediatr Surg Int. 2010 Feb. 26 (2):157-60. [QxMD MEDLINE Link].
O. Obinwa, M. Casidy, and J. Flynn. The microbiology of bacterial peritonitis due to appendicitis in children. Irish Journal Med Science. 2014. 183(4):pp 585–591. [QxMD MEDLINE Link].

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