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Anerobic and gram negative coverage is typically used preoperative for appendicitis.

Cultures obtained from children with complicated appendicitis are typically polymicrobial including a broad range aerobic and anerobic pathogens including Escherichia coli, Streptococcus species (especially S anginosus), Bacteroides species, Pseudomonas aeruginosa, and Enterococcus species.

There are many regimens for empiric therapy for preoperative for appendicitis including cefazolin with metronidazole, ceftriaxone with metronidazole, cefoxitin, cefotetan, ampicillin with gent and metronidazole, piperacillin/tazobactam or a carbapenem.

Note that Cefoxitin and Cefotetan are two cephamycin antibiotics commonly catagorized as second generation cephalosporins that are unique in aerobic coverage. Of these regimens only piperacillin/tazobactam or a carbapenem provide antipseudomonal coverage.

Non-surgical management with antimicrobials alone is being studied.


Bradly JS (ed.) (2018) Nelson's Pediatric Antimicrobial Therapy 24th edition. Itasca, IL:American Academy of Pediatrics

Pathways from CHOP, Seattle Childrens and OHSU.

Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013 Feb;14(1):73-156. PMID 23461695

Bradley JS, Behrendt CE, Arrieta AC, Harrison CJ, Loeffler AM, Iaconis JP, Wald ER. Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis. Pediatr Infect Dis J. 2001 Jan;20(1):19-24. PMID 11176562

Viel-Thériault I, Bettolli M, Toye B, Harrison MA, Le Saux N. Contemporary Microbiology and Antimicrobial Treatment of Complicated Appendicitis: The Value of a Short-term Study. Pediatr Infect Dis J. 2019 Nov;38(11):e290-e294. PMID 31365479