Antibiotics a safe and viable alternative to surgery for uncomplicated appendicitis, say experts

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

However, recent studies have reported fewer problems with antibiotic therapy than surgery in patients with uncomplicated appendicitis, but results have been inconclusive.

So a team of researchers at the Nottingham Digestive Diseaeses Centre NIHR Biomedical Research Unit set out to compare the safety and efficacy of antibiotic therapy as an initial treatment for uncomplicated acute appendicitis.

They analysed the results of four randomised controlled trials involving 900 adult patients diagnosed with uncomplicated acute appendicitis. A total of 470 patients received antibiotics and 430 underwent surgery.

Differences in study design and quality were taken into account to minimise bias.

Antibiotic therapy was associated with a 63% success rate at one year and a 31% relative reduction in complications compared with surgery.

Even after excluding patients from one study who crossed over from the antibiotic group to the surgery group, a significant (39%) reduction in complications with antibiotic therapy compared with surgery remained.

Of 68 patients treated with antibiotics who were readmitted with recurrence of symptoms, four had normal appendix and 13 had complicated appendicitis. Three patients were treated successfully with another course of antibiotics.

There were no significant differences in either length of hospital stay or risk of developing complicated appendicitis between the two groups of patients.

The authors argue that the role of antibiotics in acute uncomplicated appendicitis "has been overlooked based mainly on tradition rather than evidence" and they suggest that a careful 'wait, watch and treat' policy may be adopted in patients considered to have uncomplicated appendicitis or in whom the diagnosis is uncertain.

However, they stress that for those with clear signs of perforation or peritonitis (inflammation of the abdominal wall) … early appendicectomy still remains the 'gold standard.'

They conclude that antibiotic therapy "is a safe initial therapy for patients with uncomplicated acute appendicitis" and that it "merits consideration as a primary treatment option for early uncomplicated appendicitis."

In an accompanying editorial, Dr Olaf Bakker from the Department of Surgery at the University Medical Center Utrecht in the Netherlands argues that treating appendicitis conservatively has "major certain disadvantages" as the reoccurrence rate of appendicitis is up to 20% in the first year. He argues that until more convincing and longer term results are published, "appendectomy for uncomplicated appendicitis will probably continue."

Journal reference: British Medical Journal (BMJ)

Provided by British Medical Journal