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Antibiotics could be used to treat appendicitis

Study finds antibiotics to be a feasible alternative to appendectomy for uncomplicated appendicitis

Ingrid Torjesen

Wednesday, 26 September 2018

Treating cases of “uncomplicated” appendicitis with antibiotics was found to be a feasible alternative to appendectomies, in a study* published in JAMA.

Researchers found more than six in 10 patients who were treated with antibiotics had not had their appendix removed five years later.

The study included 530 patients aged 18 to 60 years with uncomplicated acute appendicitis, confirmed by computed tomography, in Finland. The patients were randomised to undergo an appendectomy (n = 273) or receive antibiotic therapy (n = 257) between November 2009 to June 2012 and followed up for five years.

Of the 257 patients were randomised to receive antibiotic therapy (intravenous ertapenem for three days followed by seven days of oral levofloxacin and metronidazole), in total 100 (39.1%) underwent appendectomy during the five-year course of this study, including 15 patients operated on during the initial hospitalisation.

Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, two had complicated appendicitis, and seven did not have appendicitis.

At five years, the overall complication rate or surgery, such as surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms, was 24.4% in the appendectomy group and 6.5% in antibiotic group.

Length of hospital stay was similar for both groups, but the average number of days of sick leave taken was 11 days greater in the appendectomy group.

The researchers said: “Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within five years was 39.1%. This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis.

In an accompanying editorial**, Edward Livingston, deputy editor of JAMA, pointed out that once medical treatments become universally accepted in clinical practice, they are very difficult to change, even if proven wrong or harmful.

“Appendectomy for appendicitis was perceived to be a very effective way to avoid serious infection even though observations for this association were entirely anecdotal,” he said, and despite evidence from high-quality clinical trials that have definitively shown that uncomplicated appendicitis can be treated with antibiotics.

He added: “In this new era of appendicitis treatment in which the diagnosis can be made nearly error free with CT imaging, most cases of uncomplicated appendicitis can be successfully treated with antibiotics. Patients presenting with acute, noncomplicated, CT-proven appendicitis should be given an opportunity for shared decision making, understanding that there is a high probability that they can be successfully treated with antibiotics or undergo appendectomy if they do not want to worry about the chance for recurrence.”

*Salminen P,Tuominen R, Paajanen H, et al. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial. JAMA. 2018;320(12):1259-1265. doi:10.1001/jama.2018.13201.
**Livingston EH. Antibiotic Treatment for Uncomplicated Appendicitis Really Works: Results From 5 Years of Observation in the APPAC Trial. JAMA. 2018;320(12):1245-1246. doi:10.1001/jama.2018.13368.

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