Study considers antibiotics-first approach to appendicitis

(HealthDay)—An antibiotics-first approach could be considered for specific patients with appendicitis, according to a case vignette published in the May 14 issue of the New England Journal of Medicine.

David R. Flum, M.D., M.P.H., from the University of Washington in Seattle, presented a case vignette involving a 56-year-old man presenting with a two-day history of abdominal pain, whose results were consistent with appendicitis. The patient, who had three prior surgical procedures, asked about treatment with antibiotics alone.

Flum notes that the value of early appendectomy has been called into question, with data showing that longer wait time to surgery does not increase the risk of perforation but does increase the risk of surgical site infection. Trials comparing appendectomy with an antibiotics-first strategy (with appendectomy as needed) found that most patients in the antibiotics-first group can avoid appendectomy. Clinical outcomes for patients randomized to the antibiotics-first strategy are generally favorable, although metrics of success are inconsistent and trials have small samples. The success in avoiding immediate appendectomy needs to be balanced against any increase in the length of hospitalization related to a delayed rescue appendectomy, the fear and burden of recurrence, and differences in complications or quality of life.

"I recommend that, pending more information regarding the effectiveness of an antibiotics-first approach and the longer-term outcomes of this strategy, patients interested in considering an antibiotics-first approach should be encouraged to participate in clinical trials," Flum writes.

The author disclosed financial ties to the pharmaceutical industry and has provided expert testimony for Surgical Consulting.