Antibiotics Feasible as Initial Therapy for Appendicitis in Children

By Will Boggs MD

March 30, 2017

NEW YORK (Reuters Health) - In the absence of appendicolith, most children with acute uncomplicated appendicitis can be treated initially with antibiotics and avoid the need for appendectomy, according to a new meta-analysis.

"The findings of the current study suggest that pediatric patients with uncomplicated appendicitis stand a great chance to be cured by conservative/antibiotic treatment, while appendicolith is a risk factor for complicated appendicitis or recurrent appendicitis,” Dr. Libin Huang from Sichuan University in Chengdu, China told Reuters Health by email. “Doctors should keep both opportunities and risk in mind when making clinical decisions to ensure the patients receive the most appropriate treatment.”

Several randomized clinical trials have shown success rates ranging from 63% to 85% for the nonoperative treatment of acute appendicitis in adult patients.

Dr. Huang's team compared antibiotic treatment with appendectomy in their meta-analysis of four single-center prospective non-randomized controlled trials and one single-center randomized controlled trial involving a total of 404 children with uncomplicated acute appendicitis.

Nonoperative treatment was successful in 152 of 168 patients (90.5%), with success defined as resolution of symptoms without the need for surgery within 48 hours or recurrence of appendicitis within one month after treatment initiation.

Among the 16 patients with initial failure of antibiotic treatment, 11 proceeded to appendectomy within 48 hours and five had appendicitis recurrence. In all 16, pathology results confirmed appendicitis.

Forty-five patients in the antibiotic group (26.8%) underwent appendectomy during one year of follow-up, but eight of these were diagnosed as having a normal appendix by histopathologic findings, according to the March 27 JAMA Pediatrics online report.

Appendicolith, present in 30 patients allocated to antibiotics and 19 patients allocated to initial appendectomy, was associated with an increased risk and was the main cause of failure of initial antibiotic treatment.

Complication rates did not differ between the antibiotic and appendectomy groups.

Treatment costs averaged $1310 higher per patient in the appendectomy group, whereas hospital stays averaged 14.32 hours longer in the antibiotic group.

Dr. Huang said, “We hope firstly physicians could recognize that appendicitis in children is not just a ‘surgical disease’, and unnecessary surgery could also bring hazards or increase complication morbidity. Secondly, conservative/antibiotic treatment is proved to be effective in uncomplicated appendicitis, so it should be preferably considered for this type of patients. Thirdly, surgery is suggested once appendicolith is detected; this is not a direct conclusion drawn from the study but a cautious recommendation since appendicolith greatly increased the failure rate of antibiotic treatment and is a risk factor for complicated appendicitis or recurrent appendicitis.”

“Larger clinical trials are still needed to reveal more precise indicators to guide treatment for patients with acute appendicitis with appendicolith,” Dr. Huang added.

In an editorial, Dr. Monica E. Lopez and Dr. David E. Wesson from Texas Children’s Hospital and Baylor College of Medicine in Houston write, “To our knowledge, this is the first data synthesis on the effectiveness of nonoperative treatment compared with appendectomy for uncomplicated appendicitis in children.”

They add, “This study highlights the need for higher-quality clinical trials with longer follow-up and attention to patient-centered outcomes, cost utility, and shared decision making.”

At this point, they say, “there is simply insufficient evidence to warrant a change in clinical practice, and appendectomy remains the standard of care for this disease.”

In the meantime, they write, “Nonoperative treatment remains an experimental proposition meriting ongoing consideration as a treatment strategy for uncomplicated appendicitis in children. This therapeutic option should only be offered to pediatric patients under protocol in the setting of a clinical trial.”

Dr. Richard Sinert from SUNY Downstate Medical Center, Brooklyn, New York, who has studied the diagnostic accuracy of various approaches for pediatric acute appendicitis in the emergency department, told Reuters Health by email, "In the new era of shared decision making between patients (or their family), this article presents an evidence-based alternative to traditional surgery for appendicitis. I will use this article to offer a select group of patients the antibiotic alternative to surgery.”

He agreed that "this select group still needs to be better defined in future studies, such as no appendicolith, high probability of patient follow-up, etc."


JAMA Pediatr 2017.


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