Antibiotics fall short of appendectomy for uncomplicated appendicitis in children
Key takeaways:
- About one-third of children treated with antibiotics for appendicitis experienced treatment failure.
- Children in the antibiotic group were at greater risk for adverse events and had longer hospital stays.
Among children with suspected nonperforated appendicitis, antibiotic management appeared inferior to appendectomy, according to results of a large, noninferiority trial published in The Lancet.
“The outcomes of this trial offer vital evidence to guide future treatment guidelines for appendicitis,” Agostino Pierro, MD, PhD, senior author and head of general and thoracic surgery at The Hospital for Sick Children and professor of surgery at University of Toronto, said in a related press release.
Recent studies have investigated the efficacy of treating appendicitis with antibiotics to avoid potential surgical complications and unnecessary appendectomies, showing favorable outcomes. However, these have been small pilot studies, creating the need for data from larger randomized studies, according to Pierro and colleagues.
This inspired the researchers to conduct the APPY trial — a pragmatic, multicenter, parallel-group, unmasked, randomized noninferiority trial — to determine whether antibiotic treatment for uncomplicated appendicitis in children is noninferior to appendectomy.
The study included 936 children aged 5 to 16 years with suspected nonperforated appendicitis who were recruited from 11 children’s hospitals in the U.S., Canada, Finland, Sweden and Singapore between 2016 and 2021.
After stratifying patients by sex, institution and duration of symptoms, the researchers randomly assigned them 1:1 to the IV antibiotic (n = 477; 62.9% boys; median age, 10.6 years) or appendectomy (n = 459; 64.3% boys; median age, 10.9 years) groups.
The primary outcome of the study was treatment failure within 1 year. The researchers defined failure as removal of the appendix in the antibiotic group and as normal appendix based on pathology in the appendectomy group. In both groups, additional procedures that required general anesthesia also constituted failure. Secondary outcomes included complications and length of hospital stay.
At the 12-month follow-up, data were available for 846 patients (appendectomy group, n = 394; antibiotic group, n = 452). Treatment failure occurred among 7% of patients in the appendectomy group compared with 34% of patients in the antibiotic group, equating to a difference of 26.7% (90% CI, 22.4-30.9), exceeding the researcher’s noninferiority margin of 20%.
In the antibiotic group, 72 patients met the criteria for treatment failure during the index admission, whereas 81 did so after discharge. In the appendectomy group, 27 of the 28 failed appendectomies were negative appendectomies, with the other patient later undergoing anesthesia for a related procedure.
Further, 8% of patients who underwent appendectomy in the antibiotic group had normal pathology.
Results also showed a higher risk for mild to moderate adverse events related to treatment in the antibiotic group (RR = 4.3; 95% CI, 2.1-8.7). There were no deaths or serious adverse events in either group.
Finally, the researchers found that patients in the appendectomy group had a shorter hospital stay during the initial admission (1 day; interquartile range [IQR] 0.76-1.68 vs. 1.25 days; IQR, 0.92-2.09) and over 12-month follow-up (1 day; IQR, 0.75-1.7 vs. 1.6 days; IQR, 1-2.6) compared with patients in the antibiotic group, even though patients who received antibiotics returned to normal activity and school sooner and required significantly less pain medication (P < .0001 for both).
The researchers noted several limitations to this study, including that they did not collect ethnicity information and that data on treatment failure were missing for 10% of the original cohort.
“Our findings fill an important knowledge gap that will provide evidence-based talking points for discussions on treatment options with patients and families,” Pierro said in the release.
Reference:
- Antibiotics are less effective than surgery for appendicitis, finds new study. https://www.sickkids.ca/en/news/archive/2025/antibiotics-are-less-effective-than-surgery-for-appendicitis-finds-new-study. Published Jan. 23, 2025. Accessed Jan. 28, 2025.
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