4/25/2016

AppendicitisMedication:Penicillins,Cephalosporins,Aminoglycosides,Carbapenems,Fluoroquinolones,AntiinfectiveAgents,Analgesics

AppendicitisMedication
Author:SandyCraig,MDChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Dec27,2015

MedicationSummary
Thegoalsoftherapyaretoeradicatetheinfectionandtopreventcomplications.
Thus,antibioticshaveanimportantroleinthetreatmentofappendicitis,andall
such.Agentsunderconsiderationmustofferfullaerobicandanaerobiccoverage.
Thedurationoftheadministrationiscloselyrelatedtothestageofappendicitisat
thetimeofthediagnosis.
Antibioticagentsareeffectiveindecreasingtherateofpostoperativewound
infectionandinimprovingoutcomeinpatientswithappendicealabscessor
septicemia.TheSurgicalInfectionSocietyrecommendsstartingprophylactic
antibioticsbeforesurgery,usingappropriatespectrumagentsforlessthan24hours
fornonperforatedappendicitisandforlessthan5daysforperforatedappendicitis.
Regimensareofapproximatelyequalefficacy,soconsiderationshouldbegivento
featuressuchasmedicationallergy,pregnancycategory(ifapplicable),toxicity,and
cost.

Penicillins
ClassSummary
Thepenicillinsarebactericidalantibioticsthatworkagainstsensitiveorganismsat
adequateconcentrationsandinhibitthebiosynthesisofcellwallmucopeptide.
Viewfulldruginformation

Piperacillinandtazobactamsodium(Zosyn)
Thisagentisadrugcombinationofbetalactamaseinhibitorwithpiperacillin.Ithas
activityagainstsomegrampositiveorganisms,gramnegativeorganisms,and
anaerobicbacteria.Whenusedasasingleagent,itinhibitsbiosynthesisofcellwall
mucopeptideandiseffectiveduringactivemultiplicationstages.
Viewfulldruginformation

Ampicillinandsulbactam(Unasyn)
Thisagentisadrugcombinationofbetalactamaseinhibitorwithampicillin.Itis
usedasasingleagentandinterfereswithbacterialcellwallsynthesisduringactive
replication,causingbactericidalactivityagainstsusceptibleorganisms.
Ampicillin/sulbactamalsohasactivityagainstsomegrampositiveorganisms,gram
negativeorganisms(nonpseudomonalspecies),andanaerobicbacteria.
Viewfulldruginformation

Ticarcillin/clavulanate(Timentin)
Ticarcillin/clavulanateinhibitsbiosynthesisofcellwallmucopeptideandiseffective
duringthestageofactivegrowth.Itisanantipseudomonalpenicillinplusbeta
lactamaseinhibitorthatprovidescoverageagainstmostgrampositiveorganisms,
mostgramnegativeorganisms,andmostanaerobicorganisms.

Cephalosporins
ClassSummary
Cephalosporinsarestructurallyandpharmacologicallyrelatedtopenicillins.They
inhibitbacterialcellwallsynthesis,resultinginbactericidalactivity.
Viewfulldruginformation

Cefotetan(Cefotan)
Cefotetanisasecondgenerationcephalosporinthatisusedassingledrugtherapy
forbroadgramnegativeandanaerobiccoverage.Administercefotetanwith
cefoxitintoachievetheeffectivenessofsingledose.Itshalflifeis3.5hours.
Viewfulldruginformation

Cefoxitin(Mefoxin)
Thisdrugisalsoasecondgenerationcephalosporinthatisindicatedassingleagent
forthemanagementofinfectionscausedbysusceptiblegrampositivecocciand
gramnegativerods.Ithasahalflifeof0.8hours.
Viewfulldruginformation

Cefepime
Cefepimeisafourthgenerationcephalosporin.Ithasgramnegativecoverage

http://emedicine.medscape.com/article/773895medication#showall

1/5

4/25/2016

AppendicitisMedication:Penicillins,Cephalosporins,Aminoglycosides,Carbapenems,Fluoroquinolones,AntiinfectiveAgents,Analgesics

comparabletoceftazidimebuthasbettergrampositivecoverage.Cefepimeisa
zwitterionthatrapidlypenetratesgramnegativecells.

Aminoglycosides
ClassSummary
Aminoglycosideshaveconcentrationdependentbactericidalactivity.Theseagents
workbybindingtothe30Sribosome,inhibitingbacterialproteinsynthesis.
Viewfulldruginformation

Gentamicin(Gentacidin,Garamycin)
Gentamicinisanaminoglycosideantibioticusedforgramnegativecoverage,as
wellasincombinationwithanagentagainstgrampositiveorganismsandanother
oneagainstanaerobes.Gentamicinisnotthedrugofchoice,butconsiderusingthis
drugifpenicillinsorotherlesstoxicdrugsarecontraindicated,whenitisclinically
indicated,andinmixedinfectionscausedbysusceptiblestaphylococciandgram
negativeorganisms.Thisagentmaybeadministeredintravenouslyor
intramuscularlyandhasnumerousregimensthedosemustbeadjustedfor
creatinineclearanceandchangesinvolumeofdistribution.

Carbapenems
ClassSummary
Carbapenemsarestructurallyrelatedtopenicillinsandhavebroadspectrum
bactericidalactivity.Thecarbapenemsexerttheireffectbyinhibitingcellwall
synthesis,whichleadstocelldeath.Theyareactiveagainstgramnegative,gram
positive,andanaerobicorganisms.
Viewfulldruginformation

Meropenem(Merrem)
Meropenemisabactericidalbroadspectrumcarbapenemantibioticthatinhibitscell
wallsynthesis.Itisusedasasingleagentandiseffectiveagainstmostgram
positiveandgramnegativebacteria.
Viewfulldruginformation

Ertapenem
Ertapenemhasbactericidalactivitythatresultsfromtheinhibitionofcellwall
synthesisandismediatedthroughertapenembindingtopenicillinbindingproteins.
Itisstableagainsthydrolysisbyavarietyofbetalactamases,including
penicillinase,cephalosporinase,andextendedspectrumbetalactamases.

Fluoroquinolones
ClassSummary
Theseagentscanbeusedtorelieveacuteundifferentiatedabdominalpainin
patientspresentingtotheED.
Viewfulldruginformation

Ciprofloxacin(Cipro)
CiprofloxacinisafluoroquinolonethatinhibitsbacterialDNAsynthesisand,
consequently,growth,byinhibitingDNAgyraseandtopoisomerase,whichare
requiredforreplication,transcription,andtranslationofgeneticmaterial.Quinolones
havebroadactivityagainstgrampositiveandgramnegativeaerobicorganisms.
Viewfulldruginformation

Levofloxacin(Levaquin)
Levofloxacinisusedforinfectionscausedbyvariousgramnegativeorganisms,
antipseudomonalinfectionsduetomultidrugresistantgramnegativeorganisms.
Viewfulldruginformation

Moxifloxacin(Avelox)
MoxifloxacinisafluoroquinolonethatinhibitsAsubunitsofDNAgyrase,inhibiting
bacterialDNAreplicationandtranscription.

AntiinfectiveAgents
ClassSummary
Antiinfectivessuchasmetronidazoleandtigecyclineareeffectiveagainstmany
typesofbacteriathathavebecomeresistanttootherantibiotics.
Viewfulldruginformation

Metronidazole(Flagyl)
Metronidazolehasbroadgramnegativeandanaerobiccoverageandisusedin
combinationwithaminoglycosides(eg,gentamicin).Thisagentappearstobe

http://emedicine.medscape.com/article/773895medication#showall

2/5

4/25/2016

AppendicitisMedication:Penicillins,Cephalosporins,Aminoglycosides,Carbapenems,Fluoroquinolones,AntiinfectiveAgents,Analgesics

absorbedintocellsintermediatemetabolizedcompoundsbindDNAandinhibit
proteinsynthesis,causingcelldeath.
Viewfulldruginformation

Tigecycline(Tygacil)
Tigecyclineisaglycylcyclineantibioticthatisstructurallysimilartotetracycline
antibiotics.Itinhibitsbacterialproteintranslationbybindingtothe30Sribosomal
subunit,anditblocksentryofaminoacyltRNAmoleculesintotheribosomeAsite.

Analgesics
ClassSummary
Theseagentscanbeusedtorelieveacuteundifferentiatedabdominalpainin
patientspresentingtotheED.
Viewfulldruginformation

Morphinesulfate(Astramorph,Duramorph,MSContin,MSIR,
Oramorph)
Morphinesulfateisthedrugofchoiceforanalgesiabecauseofitsreliableand
predictableeffects,safetyprofile,andeaseofreversibilitywithnaloxone.Various
intravenousdosesareusedmorphinesulfateiscommonlytitratedtothedesired
effect.

ContributorInformationandDisclosures
Author
SandyCraig,MDResidencyProgramDirector,CarolinasMedicalCenterAssociateProfessor,Departmentof
EmergencyMedicine,UniversityofNorthCarolinaatChapelHillSchoolofMedicine
SandyCraig,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,SocietyforAcademic
EmergencyMedicine
Disclosure:Nothingtodisclose.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,Program
DirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserveUniversity
SchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyof
EmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
WilliamLober,MD,MSAssociateProfessor,HealthInformaticsandGlobalHealth,SchoolsofMedicine,
Nursing,andPublicHealth,UniversityofWashington
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1.PolitesSF,MohamedMI,HabermannEB,etal.Asimplealgorithmreducescomputedtomographyusein
thediagnosisofappendicitisinchildren.Surgery.2014Jun19.[Medline].
2.DouglasD.AlgorithmcutspediatricCTuseinsuspectedappendicitis.ReutersHealthInformation.July10,
2014.[FullText].
3.YehB.Evidencebasedemergencymedicine/rationalclinicalexaminationabstract.Doesthisadultpatient
haveappendicitis?.AnnEmergMed.2008Sep.52(3):3013.[Medline].
4.MarkleGB4th.Heeldropjarringtestforappendicitis.ArchSurg.1985Feb.120(2):243.[Medline].
5.ThimsenDA,TongGK,GruenbergJC.ProspectiveevaluationofCreactiveproteininpatientssuspected
tohaveacuteappendicitis.AmSurg.1989Jul.55(7):4668.[Medline].
6.deCarvalhoBR,DiogoFilhoA,FernandesC,BarraCB.[Leukocytecount,Creactiveprotein,alpha1acid
glycoproteinanderythrocytesedimentationrateinacuteappendicitis].ArqGastroenterol.2003JanMar.
40(1):2530.[Medline].
7.AlbuE,MillerBM,ChoiY,etal.DiagnosticvalueofCreactiveproteininacuteappendicitis.DisColon
Rectum.1994Jan.37(1):4951.[Medline].
8.BolandparvazS,VaseiM,OwjiAA,AtaEeN,AminA,DaneshbodY,etal.Urinary5hydroxyindoleacetic
acidasatestforearlydiagnosisofacuteappendicitis.ClinBiochem.2004Nov.37(11):9859.[Medline].

http://emedicine.medscape.com/article/773895medication#showall

3/5

4/25/2016

AppendicitisMedication:Penicillins,Cephalosporins,Aminoglycosides,Carbapenems,Fluoroquinolones,AntiinfectiveAgents,Analgesics

9.KimK,KimYH,KimSY,KimS,LeeYJ,KimKP,etal.LowdoseabdominalCTforevaluatingsuspected
appendicitis.NEnglJMed.2012Apr26.366(17):1596605.[Medline].
10.HowellJM,EddyOL,LukensTW,ThiessenME,WeingartSD,DeckerWW.Clinicalpolicy:Criticalissues
intheevaluationandmanagementofemergencydepartmentpatientswithsuspectedappendicitis.Ann
EmergMed.2010Jan.55(1):71116.[Medline].
11.[Guideline]NationalGuidelineClearinghouse(NGC).Guidelinesummary:Clinicalpolicy:criticalissuesin
theevaluationandmanagementofemergencydepartmentpatientswithsuspectedappendicitis.National
GuidelineClearinghouse(NGC),Rockville(MD).Availableathttp://guideline.gov/content.aspx?id=15598.
Accessed:November18,2013.
12.BarloonTJ,BrownBP,AbuYousefMM,WarnockN,BerbaumKS.Sonographyofacuteappendicitisin
pregnancy.AbdomImaging.1995MarApr.20(2):14951.[Medline].
13.ManterolaC,VialM,MoragaJ,AstudilloP.Analgesiainpatientswithacuteabdominalpain.Cochrane
DatabaseSystRev.2011Jan19.1:CD005660.[Medline].
14.KaramanakosSN,SdralisE,PanagiotopoulosS,KehagiasI.Laparoscopyintheemergencysetting:a
retrospectivereviewof540patientswithacuteabdominalpain.SurgLaparoscEndoscPercutanTech.
2010Apr.20(2):11924.[Medline].
15.NiwaH,HiramatsuT.Ararepresentationofappendicealdiverticulitisassociatedwithpelvicpseudocyst.
WorldJGastroenterol.2008Feb28.14(8):12935.[Medline].[FullText].
16.PlaceRC.Acuteurinaryretentionina9yearoldchild:anatypicalpresentationofacuteappendicitis.J
EmergMed.2006Aug.31(2):1735.[Medline].
17.OtoA,ErnstRD,MileskiWJ,NishinoTK,LeO,WolfeGC,etal.LocalizationofappendixwithMDCTand
influenceoffindingsonchoiceofappendectomyincision.AJRAmJRoentgenol.2006Oct.187(4):98790.
[Medline].
18.SedlakM,WagnerOJ,WildB,PapagrigoriadesS,ExadaktylosAK.Istherestillaroleforrectal
examinationinsuspectedappendicitisinadults?.AmJEmergMed.2008Mar.26(3):35960.[Medline].
19.AlvaradoA.Apracticalscorefortheearlydiagnosisofacuteappendicitis.AnnEmergMed.1986May.
15(5):55764.[Medline].
20.SchneiderC,KharbandaA,BachurR.Evaluatingappendicitisscoringsystemsusingaprospective
pediatriccohort.AnnEmergMed.2007Jun.49(6):77884,784.e1.[Medline].
21.SchneiderC,KharbandaA,BachurR.Evaluatingappendicitisscoringsystemsusingaprospective
pediatriccohort.AnnEmergMed.2007Jun.49(6):77884,784.e1.[Medline].
22.MigraineS,AtriM,BretPM,LoughJO,HincheyJE.Spontaneouslyresolvingacuteappendicitis:clinical
andsonographicdocumentation.Radiology.1997Oct.205(1):558.[Medline].
23.CobbenLP,deVanOtterlooAM,PuylaertJB.Spontaneouslyresolvingappendicitis:frequencyandnatural
historyin60patients.Radiology.2000May.215(2):34952.[Medline].
24.DueholmS,BagiP,BudM.Laboratoryaidinthediagnosisofacuteappendicitis.Ablinded,prospective
trialconcerningdiagnosticvalueofleukocytecount,neutrophildifferentialcount,andCreactiveprotein.Dis
ColonRectum.1989Oct.32(10):8559.[Medline].
25.GurleyikE,GurleyikG,UnalmiserS.AccuracyofserumCreactiveproteinmeasurementsindiagnosisof
acuteappendicitiscomparedwithsurgeon'sclinicalimpression.DisColonRectum.1995Dec.38(12):1270
4.[Medline].
26.ShakhatrehHS.TheaccuracyofCreactiveproteininthediagnosisofacuteappendicitiscomparedwith
thatofclinicaldiagnosis.MedArh.2000.54(2):10910.[Medline].
27.AsfarS,SafarH,KhoursheedM,DashtiH,alBaderA.WouldmeasurementofCreactiveproteinreduce
therateofnegativeexplorationforacuteappendicitis?.JRCollSurgEdinb.2000Feb.45(1):214.
[Medline].
28.ErkasapS,AtesE,UstunerZ,SahinA,YilmazS,YasarB,etal.Diagnosticvalueofinterleukin6andC
reactiveproteininacuteappendicitis.SwissSurg.2000.6(4):16972.[Medline].
29.GronroosJM,GronroosP.LeucocytecountandCreactiveproteininthediagnosisofacuteappendicitis.Br
JSurg.1999Apr.86(4):5014.[Medline].
30.OrtegaDeballonP,RuizdeAdanaBelbelJC,HernandezMatiasA,GarciaSeptiemJ,MorenoAzcoitaM.
Usefulnessoflaboratorydatainthemanagementofrightiliacfossapaininadults.DisColonRectum.
2008Jul.51(7):10939.[Medline].
31.GronroosJM.IstherearoleforleukocyteandCRPmeasurementsinthediagnosisofacuteappendicitisin
theelderly?.Maturitas.1999Mar15.31(3):2558.[Medline].
32.YangHR,WangYC,ChungPK,etal.Roleofleukocytecount,neutrophilpercentage,andCreactive
proteininthediagnosisofacuteappendicitisintheelderly.AmSurg.2005Apr.71(4):3447.[Medline].
33.GronroosJM.DonormalleucocytecountandCreactiveproteinvalueexcludeacuteappendicitisin
children?.ActaPaediatr.2001Jun.90(6):64951.[Medline].
34.StefanuttiG,GhirardoV,GambaP.Inflammatorymarkersforacuteappendicitisinchildren:arethey
helpful?.JPediatrSurg.2007May.42(5):7736.[Medline].
35.MohammedAA,DaghmanNA,AboudSM,OshibiHO.ThediagnosticvalueofCreactiveprotein,white
bloodcellcountandneutrophilpercentageinchildhoodappendicitis.SaudiMedJ.2004Sep.25(9):1212
5.[Medline].
36.YangHR,WangYC,ChungPK,ChenWK,JengLB,ChenRJ.Laboratorytestsinpatientswithacute
appendicitis.ANZJSurg.2006JanFeb.76(12):714.[Medline].
37.TundidorBermudezAM,AmadoDieguezJA,MontesdeOcaMastrapaJL.[Urologicalmanifestationsof
acuteappendicitis].ArchEspUrol.2005Apr.58(3):20712.[Medline].
38.RaoPM,RheaJT,RattnerDW,etal.IntroductionofappendicealCT:impactonnegativeappendectomy
andappendicealperforationrates.AnnSurg.1999Mar.229(3):3449.[Medline].
39.McGoryML,ZingmondDS,NanayakkaraD,MaggardMA,KoCY.Negativeappendectomyrate:influence

http://emedicine.medscape.com/article/773895medication#showall

4/5

4/25/2016

AppendicitisMedication:Penicillins,Cephalosporins,Aminoglycosides,Carbapenems,Fluoroquinolones,AntiinfectiveAgents,Analgesics

ofCTscans.AmSurg.2005Oct.71(10):8038.[Medline].
40.HarswickC,UyenishiAA,KordickMF,ChanSB.Clinicalguidelines,computedtomographyscan,and
negativeappendectomies:acaseseries.AmJEmergMed.2006Jan.24(1):6872.[Medline].
41.FreiSP,BondWF,BazuroRK,RichardsonDM,SierzegaGM,ReedJF.Appendicitisoutcomeswith
increasingcomputedtomographicscanning.AmJEmergMed.2008Jan.26(1):3944.[Medline].
42.PickhardtPJ,LawrenceEM,PoolerBD,BruceRJ.Diagnosticperformanceofmultidetectorcomputed
tomographyforsuspectedacuteappendicitis.AnnInternMed.2011Jun21.154(12):78996.[Medline].
43.KepnerAM,BacasnotJV,StahlmanBA.Intravenouscontrastalonevsintravenousandoralcontrast
computedtomographyforthediagnosisofappendicitisinadultEDpatients.AmJEmergMed.2012May
23.[Medline].
44.BrennerDJ,HallEJ.Computedtomographyanincreasingsourceofradiationexposure.NEnglJMed.
2007Nov29.357(22):227784.[Medline].
45.ZilbertNR,StamellEF,EzonI,SchlagerA,GinsburgHB,NadlerEP.Managementandoutcomesfor
childrenwithacuteappendicitisdifferbyhospitaltype:areasforimprovementatpublichospitals.Clin
Pediatr(Phila).2009Jun.48(5):499504.[Medline].
46.DoriaAS,MoineddinR,KellenbergerCJ,EpelmanM,BeyeneJ,SchuhS,etal.USorCTforDiagnosis
ofAppendicitisinChildrenandAdults?AMetaAnalysis.Radiology.2006Oct.241(1):8394.[Medline].
47.BoggsW.Ultrasound/MRIStrategyDiagnosesAppendicitisinKidsWithoutRadiation.MedscapeMedical
News.Availableathttp://www.medscape.com/viewarticle/821332.Accessed:March12,2014.
48.AspelundG,FingeretA,GrossE,KesslerD,KeungC,ThirumoorthiA,etal.Ultrasonography/MRIVersus
CTforDiagnosingAppendicitis.Pediatrics.2014Mar3.[Medline].
49.CobbenLP,GrootI,HaansL,BlickmanJG,PuylaertJ.MRIforclinicallysuspectedappendicitisduring
pregnancy.AJRAmJRoentgenol.2004Sep.183(3):6715.[Medline].
50.RepplingerMD,LevyJF,PeethumnongsinE,etal.Systematicreviewandmetaanalysisoftheaccuracyof
MRItodiagnoseappendicitisinthegeneralpopulation.JMagnResonImaging.2015Dec22.[Medline].
51.ThiemeME,LeeuwenburghMM,ValdehuezaZD,BoumanDE,deBruinIG,SchreursWH,etal.
DiagnosticaccuracyandpatientacceptanceofMRIinchildrenwithsuspectedappendicitis.EurRadiol.
2013Oct19.[Medline].
52.SingerDD,ThodeHCJr,SingerAJ.EffectsofpainseverityandCTimagingonanalgesiaprescriptionin
acuteappendicitis.AmJEmergMed.2016Jan.34(1):369.[Medline].
53.ErikssonS,GranstrmL.Randomizedcontrolledtrialofappendicectomyversusantibiotictherapyforacute
appendicitis.BrJSurg.1995Feb.82(2):1669.[Medline].
54.SalminenP,PaajanenH,RautioT,etal.AntibioticTherapyvsAppendectomyforTreatmentof
UncomplicatedAcuteAppendicitis:TheAPPACRandomizedClinicalTrial.JAMA.2015Jun16.313
(23):23408.[Medline].
55.BonadioW,RebillotK,UkwuomaO,SaracinoC,IskhakovA.Managementofpediatricperforated
appendicitis:comparingoutcomesusingearlyappendectomyvssolelymedicalmanagement.PediatrInfect
DisJ.2015Dec14.[Medline].
56.BickellNA,AufsesAHJr,RojasM,BodianC.Howtimeaffectstheriskofruptureinappendicitis.JAm
CollSurg.2006Mar.202(3):4016.[Medline].
57.AbouNuktaF,BakhosC,ArroyoK,KooY,MartinJ,ReinholdR,etal.Effectsofdelayingappendectomy
foracuteappendicitisfor12to24hours.ArchSurg.2006May.141(5):5046discussion5067.[Medline].
58.FairBA,KubasiakJC,JanssenI,etal.Theimpactofoperativetimingonoutcomesofappendicitis:a
NationalSurgicalQualityImprovementProjectanalysis.AmJSurg.2015Mar.209(3):498502.[Medline].
59.BoomerLA,CooperJN,AnandalwarS,etal.Delayingappendectomydoesnotleadtohigherratesof
surgicalsiteinfections:amultiinstitutionalanalysisofchildrenwithappendicitis.AnnSurg.2015Dec16.
[Medline].
60.[Guideline]KorndorfferJRJr,FellingerE,ReedW.SAGESguidelineforlaparoscopicappendectomy.Surg
Endosc.2010Apr.24(4):75761.[Medline].[FullText].
61.WilasrusmeeC,SukratB,McEvoyM,AttiaJ,ThakkinstianA.Systematicreviewandmetaanalysisof
safetyoflaparoscopicversusopenappendicectomyforsuspectedappendicitisinpregnancy.BrJSurg.
2012Nov.99(11):14708.[Medline].
62.LiangMK,LoHG,MarksJL.Stumpappendicitis:acomprehensivereviewofliterature.AmSurg.2006
Feb.72(2):1626.[Medline].
63.BarclayL.Ultrasound,CTComparabletoDetectAppendicitisinChildren.MedscapeMedicalNews.
Availableathttp://www.medscape.com/viewarticle/817370.Accessed:December9,2013.
64.LeJ,KurianJ,CohenHW,WeinbergG,ScheinfeldMH.Doclinicaloutcomessufferduringtransitiontoan
ultrasoundfirstparadigmfortheevaluationofacuteappendicitisinchildren?.AJRAmJRoentgenol.2013
Dec.201(6):134852.[Medline].
65.HurstAL,OlsonD,SommeS,etal.Oncedailyceftriaxoneplusmetronidazoleversusertapenemand/or
cefoxitinforpediatricappendicitis.JPediatricInfectDisSoc.2015Dec24.[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/773895medication#showall

5/5