Feasibility, acceptance, safety, and effectiveness of antibiotic therapy as alternative treatment approach to appendectomy in uncomplicated acute appendicitis
- 18 Downloads
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.
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.
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.
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.
KeywordsUncomplicated acute appendicitis Conservative treatment Antibiotic therapy Non-operative treatment approach Effectiveness and safety
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
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.
- 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
- 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
- 9.Coldrey EJJICS (1959) Five years of conservative treatment of acute appendicitis 32(3):255–261Google Scholar
- 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.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.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
- 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
- 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.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.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