Antibiotics May Be Feasible Alternative to Appendectomy in Acute Appendicitis

The appendectomy has been the standard treatment for acute appendicitis for more than a century, but that could change in some cases. According to a new study in JAMA, antibiotic treatment may be a feasible alternative to surgery for uncomplicated acute appendicitis, according to findings from the 5-year observational follow-up study that compared appendectomy with antibiotic treatment.

The study followed 530 patients between the ages of 18 and 60 years who had uncomplicated acute appendicitis in Finland. The patients were randomized to either undergo an appendectomy (n = 273) or receive antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole (n = 257).

“The success of antibiotic treatment for appendicitis calls into question prior beliefs that appendicitis inevitably results in serious intraabdominal infection if appendectomy is not performed,” the authors noted.

Read about inappropriate prescribing antibiotics.

Patients who were in the antibiotic group were followed up by surgeons. If the surgeons following up suspected progressive infection, perforated appendicitis, or peritonitis in a patient, they could use their clinical judgement to perform an appendectomy. The primary end point in the antibiotic group was resolution of acute appendicitis resulting in discharge from the hospital without surgery and no appendicitis for at least 1 year.

In the first year, 70 patients in the antibiotic group underwent appendectomy, and an additional 30 had an appendectomy in years 2 and 5. None of the patients who had an appendectomy in the first year of follow-up had complicated appendicitis. The cumulative incidence of recurrence of acute appendicitis was 27.3% at 1 year, 34% at 2 years, 35.2% at 3 years, 37.1% at 4 years, and 39.1% at 5 years. In years 2 through 5, 2 patients had complicated appendicitis.

The researchers also compared complications between the antibiotic and appendectomy groups. At 5 years, the appendectomy group had a significantly higher overall complication rate (24.4%) compared with the antibiotic group (6.5%). Among all patients who underwent an appendectomy (including those in the antibiotic group who eventually underwent surgery), there was no statistically significant different in the overall complication rates, which showed that there were no complications related to delaying the surgery.

Because the surgeons following up with patients were using their judgement and antibiotic treatment was not considered an acceptable way to treat appendicitis at the time of the study, 7 of the patients in the antibiotic group who underwent an appendectomy did not actually have appendicitis. If these patients had not undergone surgery, then the success rate for treating appendicitis with antibiotics would have been 63.7% (163 of 256 patients).

The authors noted that the lack of a protocol guiding decision making for surgeons following up with patients in the antibiotic group was one of the limitations of the study and resulted in more appendectomies than were necessary.

“Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within 5 years was 39.1%,” the authors concluded. “This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis.”

Reference

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.