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Antibiotics feasible option for uncomplicated acute appendicitis
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The likelihood of recurrence of uncomplicated acute appendicitis within 5 years was 39.1% among patients initially treated with antibiotics, according to findings recently published in JAMA.
“Better preoperative diagnostic capabilities enabled trials of antibiotics to treat appendicitis without surgery,” Paulina Salminen, MD, PhD, of Turku University Hospital in Finland, and colleagues wrote. “Several recent randomized clinical trials have demonstrated the feasibility of antibiotic-only treatment for appendicitis. All of these trials had relatively short and, for some, incomplete follow-up of the patients receiving antibiotic treatment.”
Researchers conducted a 5-year follow-up of patients in the Appendicitis Acuta (APPAC) randomized clinical trial. This trial consisted of 530 patients aged 18 to 60 years with CT–confirmed uncomplicated acute appendicitis randomly assigned to receive IV ertapenem for 3 days followed by oral metronidazole and levofloxacin for 7 days (n = 257) or undergo an appendectomy. The median age of the participants receiving antibiotics was 33 years, and the median age of the control group was 35 years.
Researchers found that 70 patients who initially received antibiotics but underwent appendectomy within the first year and 30 additional antibiotic-treated patients underwent appendectomy between 1 and 5 years.
In addition, of those initially treated with antibiotics, the cumulative incidence of appendicitis recurring was 34% at 2 years, 35.2% at 3 years, 37.1% at 4 years, and 39.1% at 5 years, Salimen and colleagues wrote. Of the 85 patients in antibiotic group who subsequently underwent appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, seven did not have appendicitis and two had complicated appendicitis.
In addition, researchers found that at 5 years, 60 patients in the appendectomy group and 16 in the antibiotic group had complications (abdominal pain, incisional hernias and surgical site infections), a higher incidence by 17.9 percentage points.
“The success of antibiotic treatment for appendicitis calls into question prior beliefs that appendicitis inevitably results in serious intraabdominal infection if appendectomy is not performed,” Salimen and colleagues wrote. “These results showing spontaneous resolution of uncomplicated acute appendicitis should be verified by a double-blinded placebo-controlled randomized trial.”
In a related editorial, Edward H. Livingston MD, deputy editor of JAMA, said the findings cast doubt on a longstanding tenet of medical care.
“The findings from the APPAC trial dispel the notion that uncomplicated acute appendicitis is a surgical emergency. Although patients may be concerned about the ultimate need for surgery from a health outcomes perspective, nonsurgical treatment in uncomplicated appendicitis before proceeding to surgery is a reasonable option,” he wrote.
Livingston added the findings also offer patients with uncomplicated acute appendicitis the opportunity to engage with their clinicians in shared decision-making regarding their treatment.
He also outlined potential next steps for this line of research.
“Sufficient evidence is available to indicate that antibiotics are a suitable means for treating appendicitis. Additional randomized clinical trials comparing surgery with antibiotic treatment for uncomplicated suspected appendicitis are not needed. The next phase of appendicitis research should extend findings from the APPAC trial to improve nonoperative treatment of appendicitis.” – by Janel Miller
Disclosures: Salimen reports receiving personal fees from lectures given to Lilly, Merck and Orion Pharma. No other relevant financial disclosures were reported.