Antibiotic therapy versus appendectomy showed no difference in one-year complication rates for adults with imaging-confirmed acute appendicitis.
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Key Takeaway
Consider antibiotic therapy for uncomplicated acute appendicitis, but exercise caution in patients with an appendicolith due to higher complication risks.
This review article summarizes an individual patient data meta-analysis of randomized controlled trials involving 2,101 adult patients with imaging-confirmed acute appendicitis. The analysis compared initial antibiotic therapy against appendectomy as the primary management strategies. The primary outcome assessed was the overall complication rate at one year, alongside secondary outcomes including the rate of step-up appendectomy, hospital length of stay, and time away from work.
The results indicated no significant difference in overall complication rates between the antibiotic therapy group and the appendectomy group. Specifically, 34% of patients in the antibiotic group required delayed appendectomy within one year. Among those requiring delayed surgery, 25% were found to have complicated appendicitis. Hospital length of stay and time away from work were also evaluated as secondary metrics of treatment impact.
Safety and tolerability data were not reported in the provided evidence. A critical limitation identified was the presence of an appendicolith. Patients with an appendicolith experienced significantly higher complication rates compared to those without. In this specific subgroup, 49% of patients required subsequent appendectomy, suggesting a higher risk of treatment failure with antibiotic therapy alone.
The practice relevance suggests that antibiotic therapy is a reasonable initial management strategy for adults with uncomplicated, imaging-confirmed acute appendicitis, provided patients understand the associated risks. Caution is warranted for those with an appendicolith due to the increased risk of complications and potential treatment failure observed in the study data.
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View Original Abstract ↓
BACKGROUND: Acute appendicitis is among the most common emergency presentations and has traditionally been treated with appendectomy. However, recent randomized controlled trials suggest that antibiotic therapy is a reasonable, non-operative alternative for appropriately selected patients who understand the risks. The purpose of this review article was to summarize findings from a recent individual patient data meta-analysis comparing antibiotic therapy versus appendectomy in adults with imaging-confirmed acute appendicitis.
METHODS: The reviewed meta-analysis included six randomized controlled trials encompassing 2101 adult patients. A one-stage analysis was performed applying an intention-to-treat analysis. A mixed-effects model accounted for study-level clustering. Complications were standardized using the Clavien-Dindo classification, a widely used tool for classification of surgical complications. The primary endpoint was the overall complication rate at one year, and secondary outcomes included rate of step-up appendectomy, hospital length of stay, and time away from work.
RESULTS: No significant difference in overall, major, or minor complication rates was found at one year between patients receiving initial antibiotic therapy and those undergoing appendectomy. 34% of patients treated with antibiotics required delayed appendectomy within one year and 25% of those patients were found to have complicated appendicitis. In contrast, patients with an appendicolith demonstrated significantly higher complication rates, and 49% required subsequent appendectomy.
CONCLUSIONS: Antibiotic therapy is a reasonable initial management strategy for adults with uncomplicated, imaging-confirmed acute appendicitis as long as patients understand the risks. However, caution is warranted in those with an appendicolith due to increased risk of complications and treatment failure with antibiotic therapy.
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