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Feasibility, acceptance, safety, and effectiveness of antibiotic therapy as alternative treatment approach to appendectomy in uncomplicated acute appendicitis

  • Daniela Prechal
  • Stefan Post
  • Ioanna Pechlivanidou
  • Ulrich RonellenfitschEmail author
Original Article
  • 18 Downloads

Abstract

Purpose

Based on results from randomized controlled trials, there is an increasing discussion if antibiotic treatment is an equivalent therapeutic approach to appendectomy in uncomplicated acute appendicitis. This observational prospective study evaluates its feasibility, safety, and effectiveness in clinical practice.

Methods

The study included all consecutive adults treated for acute appendicitis over an 18-month period in one hospital. Patients receiving antibiotics were compared to those treated surgically. Follow-up comprised 1 year. The primary endpoint was treatment success, defined as no secondary appendectomy during follow-up (antibiotic group) or successful appendectomy (primary surgical group). Secondary endpoints were complications, duration of hospital stay, pain intensity, and length of absence from work.

Results

54/124 (43.6%) patients were primarily treated with antibiotics and 70/124 (56.4%) surgically. Treatment success at 1 year was 77.1% (95%-CI 62.8–88%) for antibiotic and 100% for surgical treatment. Complications were non-significantly less frequent both among all patients treated with antibiotics and among patients undergoing secondary appendectomy compared to patients undergoing primary appendectomy (20.8% vs. 27.1% and 9.1% vs. 27.1%). The initial hospital stay was significantly shorter in the antibiotic group (mean 3.6 vs. 4.8 days, median 3 days, p = 0.03). After 1 year, the cumulative hospital stay was not different between groups.

Conclusions

Appendectomy remains the most effective treatment for the definitive cure of acute appendicitis. However, antibiotic therapy can be a safe alternative approach for selected patients with uncomplicated acute appendicitis.

Trial registration

DRKS00010401

Keywords

Uncomplicated acute appendicitis Conservative treatment Antibiotic therapy Non-operative treatment approach Effectiveness and safety 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (ethical committee II of the Medical Faculty Mannheim of the University of Heidelberg [2015-906W-MA]) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

References

  1. 1.
    Addiss DG, Shaffer N, Fowler BS, Tauxe RV (1990) The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 132(5):910–925CrossRefGoogle Scholar
  2. 2.
    Podda M, Cillara N, Di Saverio S, Lai A, Feroci F, Luridiana G, Agresta F, Vettoretto N (2017) Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics. Surgeon: J R Coll Surg Edinburgh Ireland 15(5):303–314.  https://doi.org/10.1016/j.surge.2017.02.001 CrossRefGoogle Scholar
  3. 3.
    Cervellin G, Mora R, Ticinesi A, Meschi T, Comelli I, Catena F, Lippi G (2016) Epidemiology and outcomes of acute abdominal pain in a large urban emergency department: retrospective analysis of 5,340 cases. Ann Transl Med 4(19):362.  https://doi.org/10.21037/atm.2016.09.10 CrossRefGoogle Scholar
  4. 4.
    Fagerstrom A, Paajanen P, Saarelainen H, Ahonen-Siirtola M, Ukkonen M, Miettinen P, Paajanen H (2017) Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit. Scand J Gastroenterol 52(10):1072–1077.  https://doi.org/10.1080/00365521.2017.1342140 CrossRefGoogle Scholar
  5. 5.
    Prechal D, Damirov F, Grilli M, Ronellenfitsch U (2019) Antibiotic therapy for acute uncomplicated appendicitis: a systematic review and meta-analysis. Int J Color Dis 34(6):963–971.  https://doi.org/10.1007/s00384-019-03296-0 CrossRefGoogle Scholar
  6. 6.
    Treutner KH, Schumpelick V (1997) Epidemiology of appendicitis. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 68(1):1–5CrossRefGoogle Scholar
  7. 7.
    Sakorafas GH, Mastoraki A, Lappas C, Sampanis D, Danias N, Smyrniotis V (2011) Conservative treatment of acute appendicitis: heresy or an effective and acceptable alternative to surgery? Eur J Gastroenterol Hepatol 23(2):121–127.  https://doi.org/10.1097/MEG.0b013e32834233b6 CrossRefGoogle Scholar
  8. 8.
    Harrison PW (1953) Appendicitis and the antibiotics. Am J Surg 85(2):160–163CrossRefGoogle Scholar
  9. 9.
    Coldrey EJJICS (1959) Five years of conservative treatment of acute appendicitis 32(3):255–261Google Scholar
  10. 10.
    Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Grönroos JM (2015) Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial. JAMA 313(23):2340–2348.  https://doi.org/10.1001/jama.2015.6154 CrossRefGoogle Scholar
  11. 11.
    Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, Karoui M, Alves A, Dousset B, Valleur P, Falissard B, Franco D (2011) Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 377(9777):1573–1579.  https://doi.org/10.1016/s0140-6736(11)60410-8 CrossRefGoogle Scholar
  12. 12.
    Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, Rex L, Badume I, Granström L (2006) Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial. World J Surg 30(6):1033–1037.  https://doi.org/10.1007/s00268-005-0304-6 CrossRefGoogle Scholar
  13. 13.
    Hansson J, Korner U, Khorram-Manesh A, Solberg A, Lundholm K (2009) Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 96(5):473–481.  https://doi.org/10.1002/bjs.6482 CrossRefGoogle Scholar
  14. 14.
    Eriksson S, Granstrom L (1995) Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 82(2):166–169CrossRefGoogle Scholar
  15. 15.
    Bhangu A, Soreide K, Di Saverio S, Assarsson JH, Drake FT (2015) Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet (London, England) 386(10000):1278–1287.  https://doi.org/10.1016/s0140-6736(15)00275-5 CrossRefGoogle Scholar
  16. 16.
    Sippola S, Gronroos J, Tuominen R, Paajanen H, Rautio T, Nordstrom P, Aarnio M, Rantanen T, Hurme S, Salminen P (2017) Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 104(10):1355–1361.  https://doi.org/10.1002/bjs.10575 CrossRefGoogle Scholar
  17. 17.
    Elder DP, Kuentz M, Holm R (2016) Antibiotic resistance: the need for a global strategy. J Pharm Sci 105(8):2278–2287.  https://doi.org/10.1016/j.xphs.2016.06.002 CrossRefGoogle Scholar
  18. 18.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefGoogle Scholar
  19. 19.
    Kadera SP, Mower WR, Krishnadasan A, Talan DA (2016) Patient perspectives on antibiotics for appendicitis at one hospital. J Surg Res 201(2):253–257.  https://doi.org/10.1016/j.jss.2015.11.016 CrossRefGoogle Scholar
  20. 20.
    Hanson AL, Crosby RD, Basson MD (2018) Patient preferences for surgery or antibiotics for the treatment of acute appendicitis. JAMA Surg 153(5):471–478.  https://doi.org/10.1001/jamasurg.2017.5310 CrossRefGoogle Scholar
  21. 21.
    Shaib WL, Assi R, Shamseddine A, Alese OB, Staley C 3rd, Memis B, Adsay V, Bekaii-Saab T, El-Rayes BF (2017) Appendiceal mucinous neoplasms: diagnosis and management. Oncologist 22(9):1107–1116.  https://doi.org/10.1634/theoncologist.2017-0081 CrossRefGoogle Scholar
  22. 22.
    Lietzen E, Gronroos JM, Mecklin JP, Leppaniemi A, Nordstrom P, Rautio T, Rantanen T, Sand J, Paajanen H, Kaljonen A, Salminen P (2019) Appendiceal neoplasm risk associated with complicated acute appendicitis-a population based study. Int J Color Dis 34(1):39–46.  https://doi.org/10.1007/s00384-018-3156-x CrossRefGoogle Scholar
  23. 23.
    Salminen P, Tuominen R, Paajanen H, Rautio T, Nordstrom P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Gronroos JM (2018) Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA 320(12):1259–1265.  https://doi.org/10.1001/jama.2018.13201 CrossRefGoogle Scholar
  24. 24.
    Ohtani H, Tamamori Y, Arimoto Y, Nishiguchi Y, Maeda K, Hirakawa K (2012) Meta-analysis of the results of randomized controlled trials that compared laparoscopic and open surgery for acute appendicitis. J Gastrointest Surg 16(10):1929–1939.  https://doi.org/10.1007/s11605-012-1972-9 CrossRefGoogle Scholar
  25. 25.
    Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, Liu Y (2010) Laparoscopic versus conventional appendectomy--a meta-analysis of randomized controlled trials. BMC Gastroenterol 10:129.  https://doi.org/10.1186/1471-230x-10-129 CrossRefGoogle Scholar
  26. 26.
    Khalil J, Muqim R, Rafique M, Khan M (2011) Laparoscopic versus open appendectomy: a comparison of primary outcome measures. Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association 17(4):236–240.  https://doi.org/10.4103/1319-3767.82574 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Medical Faculty Heidelberg, Im Neuenheimer Feld 672HeidelbergGermany
  2. 2.Department of SurgeryUniversity Medical Center Mannheim, Medical Faculty Mannheim of the University of HeidelbergMannheimGermany
  3. 3.Department of Visceral, Vascular and Endocrine SurgeryUniversity Hospital Halle (Saale)Halle (Saale)Germany

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