• 
• 

Three Part Question

In [adults 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 34-year-old female presents to the Emergency Department with abdominal pain and nausea that started 1 day ago and became more intense and moved to the right lower quadrant. She is taking an oral contraceptive pill and has no known drug allergies. Abdominal ultrasonography confirmed a diagnosis of appendicitis. She refuses laparoscopic surgery and is requesting to go home with antibiotics.

Search Strategy

Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase
(Appendicitis/drug therapy [MAJR]). LIMIT to adults AND Meta-Analysis

Search Outcome

12 total articles were found; two systematic reviews using meta-analysis were recently published and address the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Doleman B, et al January 2024 UK	13 studies covering 1675 participants randomized to antibiotics and 1683 participants randomized to appendectomy	Systematic review with meta-analysis	Mortality	8/1000 in surgery group versus 4/1000 in antibiotic group. OR 0.51 (95% CI 0.05 to 4.95)	Significant risk of bias due to lack of blinding, loss to follow up, and imprecision. There were too few data from the included studies to comment on major complications.
			Success of treatment	840/1000 in surgery group versus 764/1000 in antibiotic group. RR 0.91 (95% CI 0.87 to 0.96)
			Appendectomy in the antibiotic group after 1 year	30.7%
			Abdominal abscess within 1 year	21/1000 in surgery group versus 33/1000 in antibiotic group. RR 1.58 (95% CI 0.61 to 4.07)
			Wound infection	33/1000 in surgery group versus 3/1000 in antibiotic group. RR 0.25 (95% CI 0.09 to 0.68)
			Length of hospital stay (days)	The mean length of hospital stay after antibiotic treatment was 0.5 days higher (1.4 hours to 1 day)
Brucchi F, et al. January 2024 Italy	Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included.	Systematic review with meta-analysis	Complication-free treatment success	RR = 0.80 favoring surgery (95% CI, 0.71 to 0.90)	The significant heterogeneity limits confidence, variations in intervention expertise and the broad timespan of included RCTs may introduce confounding factors.
			Treatment efficacy based on 1-year follow-up	RR = 0.69 favoring surgery (95% CI, 0.61 to 0.77)
			Postoperative complications	RR = 0.66 favoring surgery (95% CI, 0.41 to 1.04)
			Length of hospital stay (days)	No significant difference

Comment(s)

In children, non-surgical management of appendicitis with broad-spectrum antibiotics is a viable treatment with similar rates of complication and potentially lower healthcare costs and higher patient satisfaction. Large-scale trials in adults have shown antibiotic therapy less expensive and safe, as it has a comparable rate of complications to laparoscopic appendectomy. Although up to one-third of patients treated conservatively experience a recurrence within the first year patients can be successfully treated again with antibiotic therapy [2]. If surgery is required, it does not appear to be associated with increased complications or technical difficulty. Offering nonoperative management and discussing its risks and benefits with the patient is reasonable based on this data.

Clinical Bottom Line

Nonoperative management for uncomplicated appendicitis in adults is equivalent to laparoscopic surgery in terms of complications and hospital length of stay. While its efficacy is lower than surgery, it does not seem to increase long-term complications.

References

1. Doleman B, Fonnes S, Lund JN, Boyd-Carson H, Javanmard-Emamghissi H, Moug S, Hollyman M, Tierney G, Tou S, Williams JP. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev 2024 Apr 29;4(4):CD015038
2. Brucchi F, Bracchetti G, Fugazzola P, Viganò J, Filisetti C, Ansaloni L, Dal Mas F, Cobianchi L, Danelli P. A meta-analysis and trial sequential analysis comparing nonoperative versus operative management for uncomplicated appendicitis: a focus on randomized controlled trials. World J Emerg Surg. 2024 Jan 13;19(1):2.