Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis

Abstract

IMPORTANCE An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis. OBJECTIVE To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT). DESIGN, SETTING, AND PARTICIPANTS The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period. INTERVENTIONS Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy. MAIN OUTCOMES AND MEASURES The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period. RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of −27.0% (95% CI, −31.6% to ϱ) (P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment. CONCLUSIONS AND RELEVANCE Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications.

Contribution of Diffusion-Weighted Magnetic Resonance Imaging in the Follow-Up of Uncomplicated Acute Appendicitis: Initial Results

“…The higher rate of acute relapse in the AP-PAC study might be due to the inclusion of patients with appendicoliths. In a recently published pediatric study, the recurrence rate was found to be 5.3% for patients with appendicoliths and 0% for patients without appendicoliths (31).…”

“…However, during follow-up of SA, even with a colonoscopy, diagnosis of an underlying tumor or inflammatory bowel disease may still be problematic, and imaging may be required. It has been reported that in conditions in which therapeutic alternatives to surgery are favored, patient satisfaction might be also problematic during follow-up (31). When considering these facts and patient satisfaction during follow-up, imaging may become critical.…”

Review of Operative vs. Non-Operative Management of Appendicitis in Pregnancy

“…Recently, the American College of Surgeons performed collective review on 6 key prospective randomized trials of antibiotic therapy vs. appendectomy in non-pregnant adults and concluded that antibiotic therapy is safe for approximately "3 out of 4 adults" [23, [113][114][115][116][117][118]. One of the most compelling studies showed 91% efficacy of antibiotics alone with a 14% rate of recurrent appendicitis at 1 year, but it excluded populations (children and elderly) at high risk of perforation [114].…”

Abdominal ultrasonography of the pediatric gastrointestinal tract

“…Ultrasonography of the pediatric gastrointestinal tract can result in morbidity from an associated complication such as appendiceal rupture or bowel obstruction [53,54] . Non-operative management of acute uncomplicated appendicitis in children is also used in select cases [55,56] . Symptoms of acute appendicitis are variable and can include periumbilical and/or right lower quadrant pain, anorexia, nausea, fever, and leukocytosis [54,57] .…”