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Appendicitis

Pathway Background and Objectives

Abdominal pain is a common reason for presentation to the Emergency Department, pediatric and surgical offices, and appendicitis is a common surgical etiology for this type of pain.  Over the years, the American Pediatric Surgical Association has altered their guidelines for the management of pediatric appendicitis to help decrease the following: number of CT scans used for diagnosis, inappropriate antibiotic choices and duration, need for inpatient management post-operatively. Additionally, evidence now supports non-operative management of simple appendicitis under certain conditions. The Connecticut Children’s clinical pathway was developed to ensure an optimal consistent approach to the surgical management of children who present with appendicitis. The specific objectives of this pathway are:

  • To standardize care of patients with both acute simple (non-perforated) appendicitis, complicated (acute perforated) appendicitis in the pediatric population
  • To delineate guidelines on when to consider operative vs non-operative management
  • To standardize care of patients with operative and non-operative management
  • To provide evidence-based recommendations for key elements of care for appendicitis
  • To clearly delineate discharge criteria and instructions

There is a national shortage of intravenous metronidazole. In lieu of treatment with intravenous metronidazole and ceftriaxone, CT Children’s is recommending the following:

  • Preferred alternative:
    • Cefoxitin 160mg/kg/day divided every 6 hours (max 2 grams/dose) monotherapy
  • If allergy to cephalosporins:
    • zosyn IV 400 mg/kg/day pip q6hr (max 4 g of pip/dose) monotherapy
  • If allergy to both penicillin and cephalosporins:
    • Ertapenem monotherapy. Please consult ID for appropriate management and monitoring.
      • 3 months – 12 years of age: 30 mg/kg/day div Q12h (max 500 mg/dose)
      • 13 years and older: 30 mg/kg/day once daily (max 1000 mg/dose)

Algorithm

Download Appendicitis Pathway Algorithm  Updated September 14, 2020

Quality Metrics:

  • Percentage of eligible patients treated per pathway
  • Percentage of eligible patients with appendicitis order set usage
  • Percentage of patients with appropriate post-op antibiotic selection
  • Average duration of post-op antibiotic course (days) for complicated appendicitis
  • Mean length of stay (simple, complicated stratified)

Educational Module

Download Appendicitis Educational Module

Key References

Pathway Contacts

  • Christine Rader, MD
  • Brendan Campbell, MD, MPH

Disclaimer

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.

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