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Three Part Question

In [children with acute uncomplicated appendicitis] is [treatment with antibiotics comparable to appendectomy] in [improvement of pain and acute symptoms, hospital cost, and complication rate]?

Clinical Scenario

A 14-year-old boy presents to the Emergency Department with abdominal pain that started 3 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 1966-06/18 using PubMed, CINAHL, Cochrane Library (2018), and Embase
(Appendicitis/drug therapy [MAJR]). LIMIT to children AND English

Search Outcome

213 studies were identified; one systematic review from the Cochrane library addressed the clinical question. This review, published in 2017, analyzed five studies with a combined total of 404 participants. One prospective cohort study has been recently published that was not included in the meta-analysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Steiner et al 2018 Israel	362 children with acute uncomplicated appendicitis (AUA)	Non-randomized, prospective cohort study	Success rate of conservative management	Antibiotics were 87% effective in preventing appendectomy.	Non-randomized, unblinded, single center, no surgical control group, selection bias, the majority of patients were > 5 yrs old.
			Safety of the management protocol (defined as no cases of perforation within 36-month follow-up period)	No appendiceal perforation in antibiotic group
Huang et al 2017 China	Children aged 5-18 years with acute uncomplicated appendicitis (AUA)	Meta-analysis of 5 RCTs and prospective clinical controlled trials (404 patients)	Successful treatment of AUA	Successful nonoperative treatment in 90.5% of patients	Only one RCT, small overall sample size, inconsistent antibiotic regimen, one study ended early because of a high failure rate in antibiotic group.
			Recurrence of Appendicitis within 1 year	45 patients (26.8%) underwent appendectomy with1-year follow-up
			Complication rate	No statistically significant difference was detected in the prevalence of complications
			Total hospital cost	Total cost was lower for antibiotic therapy ($1300)

Comment(s)

This recent prospective cohort study and meta-analysis provide evidence that non-operative management of acute uncomplicated appendicitis with antibiotics is a safe and effective option in children. There remains a small portion of patients for whom the treatment will fail or who will require appendectomy later, however, complication rates appear to be similar and cost of treatment is significantly lower with antibiotic management. These six studies used stringent exclusion criteria (long symptom duration and leukocytosis) to decrease the risk for complicated appendicitis. The presence of appendicolith was the main cause for the failure of antibiotic treatment. The type and duration of antibiotic treatment may also influence the outcomes.

Clinical Bottom Line

In otherwise healthy pediatric patients with radiology confirmed uncomplicated appendicitis (without appendicolith), non-surgical management with broad-spectrum antibiotics is a viable option with similar rates of complication and potentially lower healthcare costs and higher patient satisfaction.

References

1. Steiner Z, Buklan G, Gutermacher M, Litmanovitz I, Landa T, Arnon S. Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible Pediatr Surg Int 2018;34(3):283-288
2. Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis JAMA Pediatr 2017 May 1;171(5):426-434