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Antibiotics a Reasonable Alternative to Surgery for Acute Uncomplicated Appendicitis

September 25, 2018

By Reuters Staff

NEW YORK (Reuters Health) - Antibiotic therapy is a safe alternative to surgery for patients with CT-proven acute uncomplicated appendicitis, according to five-year follow up results of the Finnish APPAC randomized controlled trial.

Nearly two-thirds of patients were successfully treated with antibiotics alone, and those who did have a recurrence of appendicitis did not suffer any complications related to delaying appendectomy, Dr. Paulina Salminen from Turku University Hospital in Finland and colleagues report in the September 25 issue of JAMA.

The five-year data from APPAC are "very encouraging" and suggest that "nonsurgical treatment in uncomplicated appendicitis before proceeding to surgery is a reasonable option," JAMA deputy editor Dr. Edward Livingston writes in an editorial.

The APPAC trial was designed to test the non-inferiority of antibiotics relative to surgery. A total of 530 adults with CT-confirmed uncomplicated acute appendicitis were randomized to appendectomy (273 patients) or antibiotic therapy (257 patients) consisting of intravenous ertapenem for three days followed by seven days of oral levofloxacin and metronidazole.

The one-year results, reported in JAMA in 2015 (, failed to show that antibiotics were non-inferior to surgery, although 73% of patients treated with antibiotics (186 of 256) did not need surgery in the first year after presentation.

The researchers now report that the cumulative incidence of appendicitis recurrence in patients initially treated with antibiotics was 27% at one year (70 of 256), 34% at two years (87 of 256), 35% at three years (90 of 256), 37% at four years (95 of 256) and 39% at five years (100 of 256).

Seventy of the 100 appendicitis recurrences in the antibiotic group occurred in the first year of the study. Of the 100 patients in the antibiotic group who underwent appendectomy, seven did not actually have appendicitis. Excluding those who likely could have avoided surgery, the true failure rate for antibiotic therapy was 36% (93 of 256).

No patient who eventually needed surgery had a major complication attributable to delaying surgery.

"This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis," the researchers conclude.

Dr. Livingston agrees and adds the following in a JAMA podcast: "During the Cold War, if a sailor on an American nuclear submarine developed appendicitis, the submarine couldn't just resurface for an appendectomy. Instead the sailor was usually given a non-surgical treatment: antibiotics. Once the submarine was able to resurface, the sailor received surgery if needed. In most cases, the appendicitis resolved without surgery. Despite this, appendectomy continued to be the treatment for all cases of appendicitis. But clinical trials now show that for cases of uncomplicated acute appendicitis diagnosed by abdominal CT scan, antibiotics is a safe alternative to appendectomy as a first-line approach."

In his editorial, Dr. Livingston says, "Patients presenting with acute, noncomplicated, CT-proven appendicitis should be given an opportunity for shared decision making, understanding that there is a high probability that they can be successfully treated with antibiotics or undergo appendectomy if they do not want to worry about the chance for recurrence."

Going forward, he adds, it will be important to determine the optimal antibiotic regimen and duration of administration for acute uncomplicated appendicitis. When the APPAC trial was designed, it wasn't clear what antibiotic to use and due to concerns about the efficacy and safety of antibiotic treatment for appendicitis, a "very aggressive" regimen was used and probably warrants reconsideration, Dr. Livingston notes.

The study had no commercial funding.


JAMA 2018.

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