Table 7 Clinical pathway for patients with acute appendicitis

 • Abdominal pain: it usually has a gradual onset and increases intensity over time. It is usually relived in the supine position and aggravated by coughing or abdominal movements. Typically, there may be a short history (1 to 3 days) of migration of the pain from the peri-umbilical region to the right iliac fossa

Diagnosis

 • Nausea and/or vomiting soon after abdominal pain begins

 • Fever

 • Tenderness localized in the RLQ (often in complicated acute appendicitis)

Laboratory markers

 • Increased white blood cell count

 • Leucocyte shift to left (> 75%)

 • Increased C-reactive protein) useful in predicting the risk of complicated acute appendicitis

Scores

 • Alvarado score

 • Andersson appendicitis inflammatory response (AIR)

Adult appendicitis score (AAS)

 • Imaging

 • US

 • CT

 • MRI

Uncomplicated appendicitis

Treatment

 • Laparoscopic appendectomy (current standard surgical treatment where appropriate resources and skills are available) or open appendectomy. Post-operative antibiotics are unnecessary if source control is adequate.

 • Antibiotic therapy without surgery (in selected patients).

Complicated appendicitis

 • Laparoscopic appendectomy (current standard surgical treatment where appropriate resources and skills are available) or open appendectomy, and antibiotic therapy for 4 days if source control is adequate.

Amoxicillin/clavulanate 2.2 g every 8 h +/− gentamicin 5–7 mg/Kg every 24 h

Antibiotic therapy

Avoid Amoxicillin/clavulanate if local Enterobacteriaceae resistances > 20%

Piperacillin/tazobactam 6 g/0.75 g LD then 4 g/0.5 g every 6 h or 16 g/2 g by continuous infusion +/− gentamicin 5–7 mg/Kg every 24 h (in critically ill patients)

Cefuroxime 1.5 g every 8 h + metronidazole 500 every 8 h

Ceftriaxone 2 g every 24 h + metronidazole 500 mg every 8 h

Cefotaxime 2 g every 8 h + metronidazole 500 mg every 8 h

or

In patients with beta-lactam allergy

A fluoroquinolone-based regimen

Ciprofloxacin 400 mg every 8/12 h + metronidazole 500 mg every 8 h

or

An aminoglycoside-based regimen

Amikacin 15–20 mg/kg every 24 h + metronidazole 500 mg every 8 h

or

In patients at high risk for infection with community-acquired ESBL-producing Enterobacteriaceae

Ertapenem 1 g every 24 h