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Three Part Question

In [patients with acute non-perforated appendicitis] is [treatment with antibiotics comparable to appendectomy] in [improvement of pain and acute symptoms, hospital length of stay, and complication rate]?

Clinical Scenario

A 23 year old man presents to the Emergency Department with abdominal pain that started 2 days ago and yesterday became more intense and moved to the right lower quadrant. He has decreased appetite, two episodes of emesis today, and low-grade fever.

Search Strategy

Medline 1966-05/07 using the OVID interface, Cochrane Library (2007), PubMed clinical queries.
(exp appendicitis/drug therapy). LIMIT to human AND English

Search Outcome

153 papers were found, of which only 2 papers were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Styrud, J. et al June 2006 seden	252 men 18-50 years old with suspected acute nonperforated appendicits and a CRP level >10mg/l	Prospective, randomized controlled, not blinded. Level 2b	Level of pain, days off work, complications, and number of antibiotic-treated group that required appendectomy at 24 hours,	12% of ABX-treated group had appendectomy at 24 hours, 88% treated successfuly with ABX, hospital lenth of stay and time off work comparable in two groups, recurrence rate of appendicitis in ABX-treated group at 1 year was 15%	Study included only men, did not include description of how diagnosis of appendicitis was made, not blinded
Eriksson, S et al Feb 1995 Sweden	45 adults with high probability appendicitis ascertained by clinical symptoms, ultrasound, WBC, and CRP	Pilot prospective randomized controlled, unblinded. Level 2b	Pain/oral temperature/WBC/CRP at admission and day 1, 2, 6, 10 & 30	Antibiotic group had significant decrease in pain and WBC, no difference in CRP or oral temp, one patient in surgery group had a wound infection, 7 patients (35%) in antibiotic group had recurrence of appendicitis within 1 year	Small sample size (only 40 patients), patients originally in antibiotic group who developed increasing pain underwent surgery and were removed from the study (only one patient), not blinded

Comment(s)

It has long been accepted that the treatment for acute appendicitis is surgery. However these two studies show that in some patients appendicitis can be treated successfully with antibiotics. In the smaller study 95% of patients were initially treated successfully with antibiotics, with a 1-year appendicitis recurrence rate of 12%. In the larger study, 88% were treated successfully initially with antibiotics alone, with a 1-year recurrence rate of 14%. This seems to contradict the long-accepted tenant that the only treatment for acute appendicitis is surgery. There are some limitations to these two studies, such as the small sample size of one study, the other only consisting of adult male patients, and both being performed in Sweden with some of the same authors. While the data on antibiotics for nonperforated appendicitis is limited, there is also research being done in children on treating perforated appendicitis initially with antibiotics and then delaying appendectomy to a later time with some favorable outcomes. These studies may eventually challenge the current treatment of acute appendicitis.

Clinical Bottom Line

These studies show that the treatment of acute appendicitis with antibiotics alone shows promise for being a successful and safe treatment. This could avoid the potential additional risks of undergoing surgery for appendicitis. A large, multi-center study of men and women with carefully defined criteria for diagnosing appendicitis is needed to further address the possibility of non-surgical treatment for acute appendicitis.

References

1. Stryud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, Rex L, Badume I, Granstrom L Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prosprective Multicenter Randomized Controlled Trial World Journal of Surgery (6):1033-7, 2006 Jun.
2. Eriksson S, Grandstrom L Randomized Controlled Trial of Appendicectomy versus Antibiotic Therapy for Acute Appendicitis British Journal of Surgery 82(2):166-9, 1995 Feb