Antibiotics May Be Effective Treatment for Appendicitis

Lara C. Pullen, PhD

April 12, 2012

April 12, 2012 — Antibiotics are a safe and effective treatment for patients with uncomplicated acute appendicitis and should be considered as an initial treatment for patients with uncomplicated appendicitis, according to the results of a new meta-analysis. However, critics express concern that the recurrence rate after antibiotic treatment is too high for it to become a new gold standard treatment.

Krishna K. Varadhan, MSc, from the Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen’s Medical Centre, United Kingdom, and colleagues published the results of a meta-analysis of randomized controlled trials online April 5 in the British Medical Journal.

The authors analyzed the results of 4 randomized controlled trials involving 900 adult patients diagnosed with uncomplicated acute appendicitis. A total of 470 patients received antibiotics, and 430 underwent surgery. Patients who received antibiotic therapy had a 63% (277/438) success rate at 1 year.

The meta-analysis also showed a relative risk reduction from complications of 31% for antibiotic treatment compared with appendectomy (Mantel-Haenszel fixed risk ratio, 0.69; 95% confidence interval, 0.54 - 0.89; P = .004). A secondary analysis, which excluded the study that allowed crossover between the 2 trial groups, showed a relative risk reduction of 39% for antibiotic therapy (risk ratio, 0.61; 95% confidence interval, 0.40 - 0.92; P = .02) compared with surgery. The authors found no significant difference between the 2 treatment options with regard to length of hospital stay, efficacy of treatment, or risk for complicated appendicitis.

Of the 68 patients readmitted after antibiotic treatment, 3 were successfully retreated with antibiotics, and 65 patients (20%) had an appendectomy. Nine of these patients had perforated appendicitis, and 4 had gangrenous appendicitis.

The authors acknowledge that a more detailed evaluation should be performed to distinguish between the effects of antibiotic treatment on perforated and nonperforated appendicitis.

Surgery to remove an inflamed appendix (appendectomy) has been the mainstay of treatment for acute appendicitis since 1889, and the general assumption is that, without surgery, the risk for complications such as perforations or infection is high.

In an accompanying editorial, Olfa Bakker, MD, from the Department of Surgery at the University Medical Center Utrecht in the Netherlands, acknowledged the validity of the meta-analysis, but remained unconvinced. "The use of antibiotics as first line treatment for appendicitis has major disadvantages," he writes. "The current meta-analysis found a 20% chance of recurrence of appendicitis after conservative treatment within one year. Of these recurrences, 20% of patients presented with a perforated or gangrenous appendicitis."

"[U]ntil more convincing studies and longer term results are published, appendicectomy will probably continue to be used for uncomplicated appendicitis," he concludes.

Varadhan was funded by a research fellowship from the Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit. The other authors and Dr. Bakker have disclosed no relevant financial relationships.

BMJ. Published online April 5, 2012. Full text

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