Antibiotics Alone May Suffice for Uncomplicated Acute Appendicitis

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.