• Is it Time to Treat Most Cases of Appendicitis With Antibiotics?

Is it Time to Treat Most Cases of Appendicitis With Antibiotics?

Researchers have provided the best evidence yet that most cases of appendicitis can be treated with antibiotics alone.

For more than 100 years, the standard treatment for appendicitis has been surgery.

Appendicitis. Source: NIH

Appendicitis. Source: NIH

In the June 16 issue of JAMA, Paulina Salminen et al report that most patients who received antibiotic treatment for uncomplicated appendicitis did not require appendectomy during a 1 y follow-up period. Those who did require appendectomies during this time did not have significant complications.

Salminen et al performed a randomized controlled trial to compare antibiotics vs appendectomy in the treatment of uncomplicated acute appendicitis (confirmed by computed tomography)—meaning appendixes had not ruptured and patients had no signs of infection or other abdominal problems.

The 257 patients assigned to the antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days, followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). The 273 assigned to the surgery group underwent standard open appendectomy.

The New York Times wrote that three of four patients who took antibiotics recovered easily, and none who had surgery after taking antibiotics were worse off for having waited.

Salminen et al emphasized that their results apply only to uncomplicated appendicitis (about 80% of total cases of appendicitis). Their study excluded patients with complications such as perforated appendices or abdominal abscesses or appendicolith.

CNN reported that there have been previous studies comparing appendectomy with antibiotics, but most used clinical examination to diagnose uncomplicated appendicitis. Salminen et al made their diagnoses based on computed tomography, which is more accurate and assured that simple cases were included in the analysis.

“The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis,” wrote Edward H. Livingston, a surgeon and editor at JAMA, in an editorial that accompanied the article.

However, Philip S. Barie, a surgeon at Weill Cornell Medical College, told the New York times that antibiotics were not sufficient for more than a quarter of the patients in the study, and that this rate of failure was unacceptable. He said that patients should have the simple and safe operation to remove their appendix, to take care of the problem quickly and permanently.

The high failure rate of antibiotic therapy suggests that it is not ready for the clinic, Curtis Wray (associate professor of surgery, University of Texas Health Science Center at Houston), told CNN. He added that more research is required to determine which patients are the best candidates for antibiotic treatment alone.

TIME explained that 10% of Americans develop acute appendicitis at some point in their lives (300,000/y), and that appendectomy surgery has become a routine procedure.  The surgeries were successful in 272 of the 273 patients who received appendectomies in the study of Salminen et al.

The New York Times says that these authors are planning a future to trial to see if, for some patients, even antibiotics aren’t necessary—it is possible that many people with appendicitis just get better on their own.

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