Antibiotic therapy could be a safe and viable alternative to surgery for patients suffering from acute uncomplicated appendicitis, according to 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 Diseases
Centre NIHR Biomedical Research Unit set out to compare the safety and efficacy
of antibiotic therapy as an initial treatment for uncomplicated acute
They analyzed the results of four randomized controlled
trials involving 900 adult patients diagnosed with uncomplicated acute
appendicitis. A total of 470 patients received antibiotics and 430 underwent
Differences in study design and quality were taken into
account to minimize 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
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
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
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 re-occurrence 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."