A meta-analysis was conducted of randomized trials and prospective controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in children 5-18 years of age. The primary outcome was the success rate of antibiotic therapy, defined as resolution of symptoms without the need for surgery within 48 hours or recurrence of appendicitis within one month after treatment initiation. Other outcomes included complications, re-admissions, length of stay, total cost, and days of disability. The quality of randomized clinical trials was evaluated using the Cochrane Collaboration risk for bias assessment tool, and the quality of cohort studies was measured in accordance with the Newcastle-Ottawa criteria.

There were 527 articles evaluated, and five unique studies were selected for meta-analysis, including four single-center, prospective, nonrandomized, controlled trials and one single-center, randomized, controlled trial. There were 404 unique patients 5-15 years of age with uncomplicated appendicitis enrolled in the five studies. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a risk ratio for failure of 8.92 (95% confidence interval [CI], 2.67-29.79). Eleven patients had appendectomy within 48 hours, and five patients had recurrence of appendicitis after one month of follow-up. The risk for treatment failure in patients with an appendicolith was increased, with a risk ratio for failure of 10.43 (95% CI, 1.46-74.26).

There were no significant differences in the prevalence of other complications between the antibiotic and appendectomy groups. The difference in initial cost between groups was $1,000. Length of hospital stay was reported in three studies, with a mean difference of 14.3 more hours in the antibiotic group than in the appendectomy group (P = 0.16). Length of disability was reported in one study, with the mean length of disability of eight days (interquartile range, 5-18 days) in the antibiotic group compared to 21 days (interquartile range, 15-25 days) in the appendectomy group (P < 0.001).

Of the 168 patients in the antibiotic treatment group, 45 (26.8%) underwent appendectomy within one year because of treatment failure (10 patients), histopathologically confirmed recurrence (27 patients), or parent demand (eight patients).

COMMENTARY

This meta-analysis found that antibiotic treatment for acute uncomplicated appendicitis in children 5-15 years of age has a 90.5% initial success rate compared to appendectomy, with a risk for complications that is comparable to appendectomy. Although antibiotic treatment of acute appendicitis appears effective in many cases, there is a nearly nine-fold higher risk of treatment failure compared with appendectomy, with 26.8% of patients in the antibiotic treatment group requiring interval appendectomy. The results of this meta-analysis indicate that appendectomy should remain the standard of care for acute uncomplicated appendicitis in children.

The meta-analysis showed that initial failure was even higher in the presence of an appendicolith, which is found in about 10% of children with acute appendicitis. Medical treatment of acute appendicitis accompanied by appendicolith appears to be inappropriate.