# Acute Appendicitis (Emergency Referral) - Category: emergency - Review status: reviewed (every claim checked against a document named on this page) - Sources: Appendicitis - StatPearls, Lotfollahzadeh, Lopez & Deppen, updated 12 February 2024 - https://www.ncbi.nlm.nih.gov/books/NBK493193/ · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) · Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) · 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. · 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. - Verified date: 2026-08 ## Verified against - Appendicitis - StatPearls, Lotfollahzadeh, Lopez & Deppen, updated 12 February 2024 - https://www.ncbi.nlm.nih.gov/books/NBK493193/ - Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) - 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. - 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. ## Treatment metadata - Ceftriaxone — 1000 mg — injection - Metronidazole — 500 mg — injection - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text ACUTE APPENDICITIS (EMERGENCY REFERRAL) Sources: Appendicitis - StatPearls, Lotfollahzadeh, Lopez & Deppen, updated 12 February 2024 - https://www.ncbi.nlm.nih.gov/books/NBK493193/ · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) · Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) · 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. · 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. Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Pain often starts vaguely around the belly button before settling into the right lower abdomen [abdominal pain · right lower quadrant pain] - Pain may wake the patient from sleep or worsen with walking or coughing [cough] - Appetite loss, possible nausea and vomiting, loose stools, feeling unwell, and urinary urgency often go along with the pain [diarrhoea · malaise · nausea · poor appetite · urinary urgency · vomiting] - About 40% of patients have a fever at presentation [fever] - Symptoms usually build up gradually over 12 to 24 hours from onset SIGNS - what you find (5) - Guarding and rebound tenderness localize to McBurney's point, roughly 1.5 to 2 inches from the hip bone toward the navel [abdominal pain · guarding · rebound tenderness · right lower quadrant pain] - Dunphy's sign, pain that worsens with coughing or straining, can support the diagnosis but is not specific [cough] - Rovsing's sign is right-sided pain triggered by pressing on the left lower abdomen [abdominal pain · left lower quadrant pain · right lower quadrant pain] - A positive psoas sign, right lower pain on hip extension or resisted thigh flexion, reflects irritation of the psoas by the inflamed appendix [peritoneal signs] - Early on, physical findings can be subtle before peritoneal signs develop as inflammation progresses [peritoneal signs] TESTS (8) - White count and CRP together help distinguish uncomplicated from complicated disease; both normal has strong negative predictive value - Most patients have a white count over 10,000 cells/mm3, and 17,000 or higher tracks with complicated disease - CT with IV contrast is the preferred imaging test and is over 95% accurate in adults - CT criteria include an appendix wider than 6 to 9 mm, a wall thicker than 2 to 3 mm, fat stranding, wall enhancement, or an appendicolith - Ultrasound is preferred in children and pregnant patients to avoid radiation, though it is less sensitive than CT - On ultrasound, an appendix wider than 6 mm, an appendicolith, or increased fat echogenicity suggest appendicitis, while under 5 mm argues against it - MRI is reserved mainly for pregnant patients, especially after an inconclusive ultrasound - A modified Alvarado score of 7 or higher is strongly linked to acute appendicitis IF NOT THIS - what else fits (7) - Crohn disease can present acutely and mimic appendicitis, sometimes only distinguished at surgery by inflamed ileum - A recent viral illness points toward mesenteric adenitis rather than appendicitis - Gynecologic mimics span mittelschmerz, salpingitis, an ovarian cyst rupture, ectopic pregnancy, a tubo-ovarian abscess, endometriosis, or pelvic inflammatory disease - Marked cervical motion tenderness on bimanual exam points toward pelvic inflammatory disease instead - Testicular or ovarian torsion, epididymitis, and round ligament syndrome are other mimics depending on sex - Gastroenteritis, colitis affecting the right colon, renal colic, kidney stones, and irritable bowel disease can also mimic the presentation - A complicated cecal diverticulum is another differential to keep in mind Score Modified Alvarado score - How strongly does this point to appendicitis? Source StatPearls "Appendicitis" - disease-level clinical article Status traced to the source above !! MULTI-DRUG REGIMEN - all 2 drugs are given TOGETHER. Not a choice between them. !! the regimen: Ceftriaxone + Metronidazole Rx: Pre-operative antibiotic cover, given by the surgical team | Main treatment PRE-OPERATIVE ANTIBIOTIC COVER, GIVEN BY THE SURGICAL TEAM - give all together 1. CEFTRIAXONE [1 of 2 - GIVE ALL TOGETHER] Adult 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 Peds 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.) 3kg -> 150-225 mg/dose 4kg -> 200-300 mg/dose 5kg -> 250-375 mg/dose 6kg -> 300-450 mg/dose 7kg -> 350-525 mg/dose 8kg -> 400-600 mg/dose 9kg -> 450-675 mg/dose 10kg -> 500-750 mg/dose 11kg -> 550-825 mg/dose 12kg -> 600-900 mg/dose 13kg -> 650-975 mg/dose 14kg -> 700-1000 mg/dose (upper capped) 15kg -> 750-1000 mg/dose (upper capped) 16kg -> 800-1000 mg/dose (upper capped) 17kg -> 850-1000 mg/dose (upper capped) 18kg -> 900-1000 mg/dose (upper capped) 19kg -> 950-1000 mg/dose (upper capped) 20kg -> 1000 mg/dose (capped) 21kg -> 1000 mg/dose (capped) 22kg -> 1000 mg/dose (capped) 23kg -> 1000 mg/dose (capped) 24kg -> 1000 mg/dose (capped) 25kg -> 1000 mg/dose (capped) 26kg -> 1000 mg/dose (capped) 27kg -> 1000 mg/dose (capped) 28kg -> 1000 mg/dose (capped) 29kg -> 1000 mg/dose (capped) 30kg -> 1000 mg/dose (capped) 31kg -> 1000 mg/dose (capped) 32kg -> 1000 mg/dose (capped) 33kg -> 1000 mg/dose (capped) 34kg -> 1000 mg/dose (capped) 35kg -> 1000 mg/dose (capped) 36kg -> 1000 mg/dose (capped) 37kg -> 1000 mg/dose (capped) 38kg -> 1000 mg/dose (capped) 39kg -> 1000 mg/dose (capped) 40kg -> 1000 mg/dose (capped) 41kg -> 1000 mg/dose (capped) 42kg -> 1000 mg/dose (capped) 43kg -> 1000 mg/dose (capped) 44kg -> 1000 mg/dose (capped) 45kg -> 1000 mg/dose (capped) 46kg -> 1000 mg/dose (capped) 47kg -> 1000 mg/dose (capped) 48kg -> 1000 mg/dose (capped) 49kg -> 1000 mg/dose (capped) 50kg -> 1000 mg/dose (capped) AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source 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. Why 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. Caution GIVEN WITH METRONIDAZOLE, NOT ALONE. Ceftriaxone covers the aerobic gram-negatives; the anaerobic half of the regimen is the other drug. The referral comes first. This is the regimen the patient is being sent for - the article is explicit that antibiotics are given as the surgical team directs, and that appendicectomy, not antibiotics, remains the standard treatment. Starting an antibiotic in the clinic and reviewing tomorrow is how an appendix perforates. Contraindicated in penicillin or cephalosporin hypersensitivity. Contraindicated in the neonate given calcium-containing intravenous fluids. Where renal and hepatic impairment coexist, the formulary caps the daily dose at 2 g. The article notes that local resistance patterns, allergy and previous antibiotic exposure change the choice; the pairing above is the article's default, not an invariant rule. Egypt ZOXIDEL 1 GM PD. FOR I.M. INJ. RAMEDA > DELT... 22.00 EGP CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA) KAHIRA 29.00 EGP ZOXIDEL 1 GM PD. FOR I.V. INJ. RAMEDA > DELT... 29.00 EGP WINTRIAXONE 1 GM PD. FOR I.V INJ. SANOFI 48.00 EGP VOTRIAXONE 1 GM I.M VIAL CHEMIPHARM 56.00 EGP OFRAMAX 1 GM I.M. VIAL RAMEDA > SUN ... 71.00 EGP TRIAXONE 1 GM I.M. VIAL TABUK PHARMAC... 106.00 EGP TRIAXONE 1 GM I.V VIAL TABUK PHARMAC... 106.00 EGP 2. METRONIDAZOLE [2 of 2 - GIVE ALL TOGETHER] Adult 500 mg intravenously or orally every 8 hours, as part of a combination - Until appendicectomy - this is cover for the operation, not a course Peds 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.) 3kg -> 67.5-120 mg/day 4kg -> 90-160 mg/day 5kg -> 112.5-200 mg/day 6kg -> 135-240 mg/day 7kg -> 157.5-280 mg/day 8kg -> 180-320 mg/day 9kg -> 202.5-360 mg/day 10kg -> 225-400 mg/day 11kg -> 247.5-440 mg/day 12kg -> 270-480 mg/day 13kg -> 292.5-520 mg/day 14kg -> 315-560 mg/day 15kg -> 337.5-600 mg/day 16kg -> 360-640 mg/day 17kg -> 382.5-680 mg/day 18kg -> 405-720 mg/day 19kg -> 427.5-760 mg/day 20kg -> 450-800 mg/day 21kg -> 472.5-840 mg/day 22kg -> 495-880 mg/day 23kg -> 517.5-920 mg/day 24kg -> 540-960 mg/day 25kg -> 562.5-1000 mg/day 26kg -> 585-1040 mg/day 27kg -> 607.5-1080 mg/day 28kg -> 630-1120 mg/day 29kg -> 652.5-1160 mg/day 30kg -> 675-1200 mg/day 31kg -> 697.5-1240 mg/day 32kg -> 720-1280 mg/day 33kg -> 742.5-1320 mg/day 34kg -> 765-1360 mg/day 35kg -> 787.5-1400 mg/day 36kg -> 810-1440 mg/day 37kg -> 832.5-1480 mg/day 38kg -> 855-1520 mg/day 39kg -> 877.5-1560 mg/day 40kg -> 900-1600 mg/day 41kg -> 922.5-1640 mg/day 42kg -> 945-1680 mg/day 43kg -> 967.5-1720 mg/day 44kg -> 990-1760 mg/day 45kg -> 1012.5-1800 mg/day 46kg -> 1035-1840 mg/day 47kg -> 1057.5-1880 mg/day 48kg -> 1080-1920 mg/day 49kg -> 1102.5-1960 mg/day 50kg -> 1125-2000 mg/day Source 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. Why 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. Caution GIVEN WITH CEFTRIAXONE, NOT ALONE. It covers anaerobes only. The referral comes first; this is what the receiving team gives. No alcohol during treatment or for 3 days after it, and not within 2 weeks of disulfiram - the formulary contraindicates all three. Contraindicated in the first trimester when the indication is trichomoniasis, and in active neurological disorders, blood dyscrasia, hypothyroidism and hypoadrenalism. Halve the dose in severe hepatic impairment (Child-Pugh C). The article offers clindamycin as the alternative anaerobic agent to metronidazole. Only one of the two is given, alongside the cephalosporin. How long it runs after the operation is a separate question, and the two documents differ: the article gives no antibiotic at all after an uncomplicated appendicectomy and a 4-day course where the appendix was complicated, while the formulary's intra-abdominal figure is 4 to 7 days following adequate source control. Both are recorded; the operating team decides which applies. The article records that uncomplicated appendicectomy needs no antibiotic afterwards, while complicated disease is scheduled for a 4-day course, and that a periappendiceal abscess may need percutaneous drainage with broad-spectrum antibiotics for several weeks before an interval appendicectomy. Egypt METRONIDAZOLE-OTSUKA 500MG /100ML I.V. INF. 100 ML OTSUKA 20.00 EGP FLAZOL 500MG/100ML I.V.INFUSION EL NILE. 31.00 EGP AMRIZOLE 500 MG VIAL 100 ML AMRIYA 47.00 EGP METROFLAG 500MG/100ML VIAL FOR I.V. INF. ARABCOMED-EGYPT 47.00 EGP MAIN TREATMENT 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult 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 Peds 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. Source No dose - referral pathway, no medicine given in primary care Caution SURGICAL EMERGENCY. StatPearls puts rupture at roughly 2% of cases by about 36 hours from when symptoms begin, and has that figure climbing a further 5% or so with each 12 hours that go by without proper medical treatment. The primary treatment remains surgical - StatPearls has surgery as the first option for acute appendicitis still, and antibiotics alone are a hospital decision, not a primary- care one. An Alvarado score of 7 or more is significantly associated with appendicitis, but a LOW score does not exclude it and must not be used to send someone home. Pregnancy, the elderly and the immunosuppressed present atypically and are the ones who perforate. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)