Medication Summary
The goals of therapy are to eradicate the infection and to prevent complications. Thus, antibiotics have an important role in the treatment of appendicitis, and all such. Agents under consideration must offer full aerobic and anaerobic coverage. The duration of the administration is closely related to the stage of appendicitis at the time of the diagnosis.
Antibiotic agents are effective in decreasing the rate of postoperative wound infection and in improving outcome in patients with appendiceal abscess or septicemia. The Surgical Infection Society recommends starting prophylactic antibiotics before surgery, using appropriate spectrum agents for less than 24 hours for nonperforated appendicitis and for less than 5 days for perforated appendicitis. Regimens are of approximately equal efficacy, so consideration should be given to features such as medication allergy, pregnancy category (if applicable), toxicity, and cost.
Penicillins
Class Summary
The penicillins are bactericidal antibiotics that work against sensitive organisms at adequate concentrations and inhibit the biosynthesis of cell wall mucopeptide.
Piperacillin and tazobactam sodium (Zosyn)
This agent is a drug combination of beta-lactamase inhibitor with piperacillin. It has activity against some gram-positive organisms, gram-negative organisms, and anaerobic bacteria. When used as a single agent, it inhibits biosynthesis of cell wall mucopeptide and is effective during active multiplication stages.
Ampicillin and sulbactam (Unasyn)
This agent is a drug combination of beta-lactamase inhibitor with ampicillin. It is used as a single agent and interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Ampicillin/sulbactam also has activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria.
Ticarcillin/clavulanate (Timentin)
Ticarcillin/clavulanate inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth. It is an antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive organisms, most gram-negative organisms, and most anaerobic organisms.
Cephalosporins
Class Summary
Cephalosporins are structurally and pharmacologically related to penicillins. They inhibit bacterial cell wall synthesis, resulting in bactericidal activity.
Cefotetan (Cefotan)
Cefotetan is a second-generation cephalosporin that is used as single-drug therapy for broad gram-negative and anaerobic coverage. Administer cefotetan with cefoxitin to achieve the effectiveness of single dose. Its half-life is 3.5 hours.
Cefoxitin (Mefoxin)
This drug is also a second-generation cephalosporin that is indicated as single agent for the management of infections caused by susceptible gram-positive cocci and gram-negative rods. It has a half-life of 0.8 hours.
Cefepime
Cefepime is a fourth-generation cephalosporin. It has gram-negative coverage comparable to ceftazidime but has better gram-positive coverage. Cefepime is a zwitter ion that rapidly penetrates gram-negative cells.
Aminoglycosides
Class Summary
Aminoglycosides have concentration-dependent bactericidal activity. These agents work by binding to the 30S ribosome, inhibiting bacterial protein synthesis.
Gentamicin (Gentacidin, Garamycin)
Gentamicin is an aminoglycoside antibiotic used for gram-negative coverage, as well as in combination with an agent against gram-positive organisms and another one against anaerobes. Gentamicin is not the drug of choice, but consider using this drug if penicillins or other less toxic drugs are contraindicated, when it is clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. This agent may be administered intravenously or intramuscularly and has numerous regimens; the dose must be adjusted for creatinine clearance and changes in volume of distribution.
Carbapenems
Class Summary
Carbapenems are structurally related to penicillins and have broad-spectrum bactericidal activity. The carbapenems exert their effect by inhibiting cell wall synthesis, which leads to cell death. They are active against gram-negative, gram-positive, and anaerobic organisms.
Meropenem (Merrem)
Meropenem is a bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. It is used as a single agent and is effective against most gram-positive and gram-negative bacteria.
Ertapenem
Ertapenem has bactericidal activity that results from the inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin-binding proteins. It is stable against hydrolysis by a variety of beta-lactamases, including penicillinase, cephalosporinase, and extended-spectrum beta-lactamases.
Fluoroquinolones
Class Summary
These agents can be used to relieve acute undifferentiated abdominal pain in patients presenting to the ED.
Ciprofloxacin (Cipro)
Ciprofloxacin is a fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerase, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms.
Levofloxacin (Levaquin)
Levofloxacin is used for infections caused by various gram-negative organisms, antipseudomonal infections due to multidrug resistant gram-negative organisms.
Moxifloxacin (Avelox)
Moxifloxacin is a fluoroquinolone that inhibits A subunits of DNA gyrase, inhibiting bacterial DNA replication and transcription.
Anti-infective Agents
Class Summary
Anti-infectives such as metronidazole and tigecycline are effective against many types of bacteria that have become resistant to other antibiotics.
Metronidazole (Flagyl)
Metronidazole has broad gram-negative and anaerobic coverage and is used in combination with aminoglycosides (eg, gentamicin). This agent appears to be absorbed into cells; intermediate metabolized compounds bind DNA and inhibit protein synthesis, causing cell death.
Tigecycline (Tygacil)
Tigecycline is a glycylcycline antibiotic that is structurally similar to tetracycline antibiotics. It inhibits bacterial protein translation by binding to the 30S ribosomal subunit, and it blocks entry of amino-acyl tRNA molecules into the ribosome A site.
Analgesics
Class Summary
These agents can be used to relieve acute undifferentiated abdominal pain in patients presenting to the ED.
Morphine sulfate (Astramorph, Duramorph, MS Contin, MSIR, Oramorph)
Morphine sulfate is the drug of choice for analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various intravenous doses are used; morphine sulfate is commonly titrated to the desired effect.
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CT scan reveals an enlarged appendix with thickened walls, which do not fill with colonic contrast agent, lying adjacent to the right psoas muscle.
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Sagittal graded compression transabdominal sonogram shows an acutely inflamed appendix. The tubular structure is noncompressible, lacks peristalsis, and measures greater than 6 mm in diameter. A thin rim of periappendiceal fluid is present.
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Transverse graded compression transabdominal sonogram of an acutely inflamed appendix. Note the targetlike appearance due to thickened wall and surrounding loculated fluid collection.
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Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled WBCs in the right lower quadrant consistent with acute appendicitis.
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Perforated appendicitis.
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Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis.
Tables
Characteristic |
Score |
M = Migration of pain to the RLQ |
1 |
A = Anorexia |
1 |
N = Nausea and vomiting |
1 |
T = Tenderness in RLQ |
2 |
R = Rebound pain |
1 |
E = Elevated temperature |
1 |
L = Leukocytosis |
2 |
S = Shift of WBCs to the left |
1 |
Total |
10 |
Source: Alvarado. [18] |
|
RLQ = right lower quadrant; WBCs = white blood cells |
|
WBC (× 10,000) |
Likelihood Ratio (95% CI) |
4-7 |
0.10 (0-0.39) |
7-9 |
0.52 (0-1.57) |
9-11 |
0.29 (0-0.62) |
11-13 |
2.8 (1.2-4.4) |
13-15 |
1.7 (0-3.6) |
15-17 |
2.8 (0-6.0) |
17-19 |
3.5 (0-10) |
19-22 |
∞ |
Source: Dueholm et al. [23] |
|
CI = confidence interval; WBC = white blood cell. |
|
