Antibiotics May Be Enough for Appendicitis

For uncomplicated appendicitis, using antibiotics first may preclude the need to remove the appendix and reduce complications, a meta-analysis suggested.

In a meta-analysis of four randomized trials, initial treatment with antibiotics prevented the need for appendectomy in 63% of patients, according to Dileep Lobo, DM, of Nottingham University Hospitals in England, and colleagues.

In addition, first-line antibiotic treatment was associated with a relative 31% lower risk of complications compared with appendectomy (18% versus 25%; RR 0.69, 95% CI 0.54 to 0.89), the researchers reported online in BMJ.

Based on the results, they said that “initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.”

“Given the increase in nonperforated appendicitis diagnosed with more frequent use of computed tomography and laparoscopy, a careful ‘wait, watch, and treat’ policy may be adopted in those patients considered to have uncomplicated appendicitis or in whom the diagnosis is uncertain, as in these patients correct diagnosis rather than an early appendectomy is the key,” they wrote.

They added that early appendectomy remains the gold standard for patients with clear signs of perforation or peritonitis.

Since 1889, appendectomy - the surgical removal of the appendix - has been the go-to treatment for acute appendicitis. But a new study finds that going under the knife may not be necessary. For two-thirds of patients, antibiotics may work just as well, or better, than surgery.

Researchers from the Nottingham Digestive Diseaeses Centre NIHR Biomedical Research Unit report that patients with uncomplicated appendicitis may be safely and effectively treated initially with standard antibiotics. Using antibiotics also significantly reduces the risk of complications and death, compared with surgery, the researchers found. For complicated cases, however - those involving perforated appendixes, for example - still need surgical removal.

To compare outcomes, the researchers performed a meta-analysis of four randomized controlled trials involving a total of 900 adult patients with uncomplicated acute appendicitis. Of the 900 participants, 470 received antibiotics and 430 had surgery.

For more than a century, appendectomy has been the go-to treatment for appendicitis based on the belief that the disease often progresses from uncomplicated appendicitis to perforation.

Only 20% of patients present with complicated disease, however, and the preferred use of appendectomy has been called into question by recent reports of less morbidity with an antibiotic-first approach.

Not everyone is convinced that antibiotics will supplant surgery for simple appendicitis just yet. The antibiotic-only approach has “major certain disadvantages,” Olaf Bakker, of the University Medical Center Utrecht in the Netherlands, noted in an accompanying essay in BMJ. In the first year after first being diagnosed with appendicitis, for example, as many as one out of five people will suffer symptoms again.

So until those stats improve, Bakker noted, “appendectomy for uncomplicated appendicitis will probably continue.”

To compare the two approaches, Lobo and colleagues performed a meta-analysis of four randomized controlled trials with a total of 900 adult patients with suspected uncomplicated acute appendicitis. Routine radiological confirmation of the diagnosis was not used in all of the studies.

The primary outcome was the rate of complications, which were defined as perforated or gangrenous appendicitis or peritonitis and wound infection (for patients who failed antibiotics and underwent surgery) in the antibiotic group and as perforated appendicitis or peritonitis and wound infection in the appendectomy group.

Initial use of antibiotics was associated with a significant reduction in complications, even after excluding the study that had a large number of patients who crossed over from the antibiotic group to the appendectomy group after randomization (12% versus 19%; RR 0.61, 95% CI 0.40 to 0.92).

Overall, 20% of the patients in the antibiotic group had an appendectomy after readmission to the hospital within one year, and of those, nine had perforated appendicitis and four had gangrenous disease. The overall risk of perforated or gangrenous appendicitis in the antibiotic group was 7.4%.

Appendicitis is the most common surgical emergency in the pediatric population. Despite the widespread prevalence of the disease, there is little consensus regarding the diagnosis and management of appendicitis. In 2000, a survey of all members of the American Pediatric Surgical Association demonstrated controversy in virtually every aspect of the management of appendicitis. With respect to antibiotic therapy, there was considerable variability in the choice, duration, and route of administration of antibiotics for both acute and perforated appendicitis.

What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis?
In patients with nonperforated appendicitis, there is strong evidence that children should receive preoperative broadspectrum antibiotics (Grade A). A Cochrane Database review looking at both adults and children support that a single dose of broad-spectrum antibiotics, given preoperatively is effective in decreasing wound infection and abscess formation. This meta-analysis demonstrated that preoperative antibiotics significantly decreased the risk of wound infection and postoperative abscess compared to placebo. The studies that were reviewed used different antibiotics, including cefoxitin, piperacillin/ tazobactam, and others. This meta-analysis did include both adult and pediatric patients. There was no evidence supporting the use of a second dose of antibiotic in the postoperative period.


Antibiotics and appendicitis in the pediatric population:
an American Pediatric Surgical Association Outcomes and
Clinical Trials Committee Systematic Review

There were no differences between the two groups in treatment efficacy, length of stay, or the risk of developing complicated appendicitis.

In an accompanying editorial, Olaf Bakker, MD, of the University Medical Center Utrecht in the Netherlands, said that, at first glance, the findings appear to contradict the accepted dogma of prompt appendectomy.

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