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Debate Continues: Antibiotics Only or Surgery for Uncomplicated Appendicitis?

COLUMBUS, OH – When a child presents to the emergency department with uncomplicated acute appendicitis, is using antibiotics alone for treatment a reasonable alternative to surgery if that is the family’s choice?

It’s all according to who you ask.

A study led by researchers at Nationwide Children's Hospital in Columbus, OH, found that three out of four children with uncomplicated appendicitis had been successfully treated with antibiotics alone at one year follow-up. The report, published recently in JAMA Surgery, notes that, in comparison with urgent appendectomy, non-operative management was associated with less recovery time, lower health costs, and no difference in the rate of complications at one year.

"Families who choose to treat their child's appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn't work, have expressed that, for them, it was worth it to try antibiotics to avoid surgery," said lead author Peter C. Minneci, MD, in a Nationwide Children’s press release. "These patients avoided the risks of surgery and anesthesia, and they quickly went back to their activities."

A surgeon-led analysis -- which looked only at adults -- argues, however, that it is too early to change the standard treatment of appendicitis in the United States to initial antibiotic therapy only, rather than surgical removal of the appendix.

The ”article in press” on the Journal of the American College of Surgeons website notes that prompt appendectomy has been the standard treatment of appendicitis for more than 120 years. It also refers to articles over the last two decades concluding that some patients with acute uncomplicated appendicitis can be treated with antibiotics alone.

"Despite the generally low rate of complications after appendectomy, some U.S. physicians and the public are questioning whether we should change to non-operative treatment of appendicitis, as many surgeons in Europe already have done," said that study's lead investigator, Anne P. Ehlers, MD, of the University of Washington, Seattle.

"What we found in our review is that antibiotics-first treatment of appendicitis is probably safe for adults and successful in 3 out of 4 patients,” Ehlers added in an American College of Surgeons press release. “However, there are many unanswered questions about outcomes of antibiotics-first treatment that patients have told us are important to them.”

The Nationwide Children’s study enrolled 102 patients ages 7 to 17 who were diagnosed with uncomplicated acute appendicitis between October 2012 and October 2013. Participants had early/mild appendicitis, with abdominal pain for no more than 48 hours, a white blood cell count below 18,000, had undergone an ultrasound or CT scan to rule out rupture and to verify that their appendix was 1.1 centimeter thick or smaller and had no evidence of an abscess or fecalith.

The 37 patients whose families had opted for antibiotics were admitted to the hospital and received IV antibiotics for at least 24 hours, followed by oral antibiotics after discharge for a total of 10 days; 95% showed improvement within 24 hours and were discharged without undergoing surgery, according to the results.

Surgery was chosen for another 65 patients, with rates of appendicitis-related medical care within 30 days found to be similar between the groups.

Two patients in the non-operative group were readmitted within 30 days for an appendectomy, but, at one year after discharge, three out of four patients in the non-operative group did not have appendicitis again and had not undergone surgery, study authors report.