Antibiotics versus appendicectomy against uncomplicated acute appendicitis.

[Argirios Argiriou]

Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials.

BMJ 2012; 344 doi: 10.1136/bmj.e2156 (Published 5 April 2012)

    Krishna K Varadhan, research fellow1,
    Keith R Neal, professor12,
    Dileep N Lobo, professor1

Abstract

Objective To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis.

Design Meta-analysis of randomised controlled trials.

Population Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations.

Interventions Antibiotic treatment versus appendicectomy.

Outcome measures The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions.

Results Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I2=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I2=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis.

Conclusion Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.


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[Ορθοπαιδικός]

  Μα το σκουλίκι έχει πολλούς λόγους για να "βγει". Κυρίως αν είναι "αμερικάνικο"....

[Argirios Argiriou]

June 16, 2015

Antibiotics Instead of Surgery for Appendicitis?

Daniel J. Pallin, MD, MPH reviewing Salminen P et al. JAMA 2015 Jun 16. Livingston E and Vons C. JAMA 2015 Jun 16.

A recurrence occurred (and was treated surgically) in 27% of the antibiotic group in this randomized trial.

Prior studies of antibiotics instead of surgery for appendicitis have yielded conflicting results (NEJM JW Emerg Med Jun 2014 and Ann Surg 2014 [e-pub]; NEJM JW Emerg Med Jul 2014 and J Am Coll Surg 2014; 218:905 and J Am Coll Surg 2014 [e-pub]; NEJM JW Emerg Med Jul 2011 and Lancet 2011; 377:1573). In a multicenter Finnish trial, investigators randomized 530 patients (aged 18–60 years) with uncomplicated acute appendicitis confirmed by computed tomography (CT) to surgery or antibiotic treatment. The antibiotic group received intravenous ertapenem (1 g per day) for 3 days followed by oral levofloxacin (500 mg once per day) plus metronidazole (500 mg 3 times per day) for 1 week. Patients were followed for 1 year.

Successful appendectomy, the main outcome in the surgery group, was realized in all but one patient. That patient's symptoms resolved, obviating the need for appendectomy. In the antibiotic group, treatment efficacy was defined as resolution of appendicitis with no need for appendectomy and no recurrence within 1 year. Of patients randomized to the antibiotics group, 27% had an appendectomy within 1 year. No patient died from appendicitis. Complications, such as surgical site infections and possible adhesion-related gastrointestinal symptoms, were significantly more prevalent in the surgery group (20%) than in the antibiotic group (3%).

COMMENT

Antibiotic treatment as an alternative to surgery is controversial. This study shows that more than a quarter of patients treated with antibiotics instead of surgery have a recurrence within 1 year. The take-home message is that for some patients with CT-proven uncomplicated appendicitis, antibiotic treatment may be a reasonable option — according to patient preferences, individualized surgical risk, and other factors — so long as everyone understands that the chance of a recurrence is quite high.

EDITOR DISCLOSURES AT TIME OF PUBLICATION

Disclosures for Daniel J. Pallin, MD, MPH at time of publication
Grant / Research supportNIH
Leadership positions in professional societiesSociety for Academic Emergency Medicine (Co-Chair, Scientific Subcommittee of Program Committee)

CITATION(S):

Salminen P et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA 2015 Jun 16; 313:2340. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)
Livingston E and Vons C.Treating appendicitis without surgery. JAMA 2015 Jun 16; 313:2327. (Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος)

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