Acute Appendicitis (Emergency Referral)

1 to 2 g intravenously or intramuscularly once daily, or the same total split into two doses. Maximum 4 g daily. - Until appendicectomy - this is cover for the operation, not a course

50-75 mg/kg/dose [child max 1000 mg]

(Infants, children and adolescents, mild to moderate infection: 50 to 75 mg/kg per dose intramuscularly or intravenously once daily, maximum 1,000 mg per day. Because it is given once daily, that daily maximum is also the per-dose ceiling shown above. Severe infection is dosed differently, at 100 mg/kg/day divided every 12 to 24 hours. Appendicitis is the commonest abdominal surgical emergency of childhood, and the dose is given by the surgical team.)

WATCH group - carries resistance cost. Egyptian EML 2025.

Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - general adult dosage 1 to 2 g intravenously or intramuscularly once daily or divided twice daily, maximum 4 g daily, with community-acquired intra-abdominal infection among the named indications.

The appendicitis article's antibiotic cover targets aerobes and anaerobes together, and names a third-generation cephalosporin such as ceftriaxone for the aerobic gram-negative half. It also says antibiotics are given intravenously as directed by the surgical care team while the patient is kept nil by mouth and hydrated with crystalloid. Eight ceftriaxone 1 g products are marketed in Egypt.

500 mg intravenously or orally every 8 hours, as part of a combination - Until appendicectomy - this is cover for the operation, not a course

22.5-40 mg/kg/day [child max 4000 mg]

(Infants, children and adolescents, intravenous: 22.5 to 40 mg/kg/day in 3 or 4 divided doses, maximum 4,000 mg per day. By mouth the formulary gives a different band - 15 to 50 mg/kg/day in 3 divided doses, maximum 2,250 mg per day - so the route decides which applies. The grid above is the intravenous one, because that is the route used before appendicectomy.)

Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) - intra-abdominal infection, oral or intravenous 500 mg every 8 hours as part of an appropriate combination regimen, for 4 to 7 days following adequate source control.

The appendicitis article pairs the cephalosporin with an anaerobic agent. Metronidazole is the drug the Egyptian formulary doses for intra-abdominal infection, and it is stocked as a ready-to-use 500 mg in 100 mL infusion, which is what a district hospital will have.

Same-day surgical referral. Pain that begins diffuse or around the umbilicus and then localises to the right lower quadrant is the classic course; fever is present in about 40%. Do NOT start antibiotics in the clinic and review tomorrow, and do NOT let a normal temperature or a soft abdomen early on reassure you - the appendix can perforate while the patient is still walking. Analgesia does not mask the diagnosis and should not be withheld. - Refer, with advice

Children present less typically and perforate sooner. A child with abdominal pain, vomiting and any right-sided tenderness goes to hospital the same day, not to a review appointment.

No dose - referral pathway, no medicine given in primary care