Treating appendicitis with antibiotics

Surgical removal of the inflamed appendix has been the standard of care for over a 120 years.  More than 300,000 appendectomies are performed annually in the United States.  Even though appendectomy is generally well tolerated, it is a major surgical procedure and can be associated with postoperative morbidity.

A recent study by Salminen et al.  from Turku University Hospital in Finland found that three of four patients with appendicitis treated with antibiotics did not need to have their appendix surgically removed. Those who eventually needed the surgery were not harmed by postponing the procedure as there were no intra-abdominal abscesses or other major complications associated with delayed appendectomy.

The study illustrated that emergency appendectomy is only indicated in those with CT-proven complicated appendicitis that can cause the appendix to rupture, which make only about one in five of patients. In contrast, those with CT- proven uncomplicated appendicitis can be treated with antibiotics.

The investigator randomly assigned 273 patients with acute appendicitis to appendectomy and 256 to a 10-day course of antibiotics. Appendectomies were successful in all but one of 273 (0.4%) patients. Among 256 patients treated with antibiotics and followed for a year, 186 (73%) did not require surgery. However, 70 (27%) percent of the patients treated with antibiotics had to have their appendix removed within a year after treatment. No patient in the antibiotic group developed a serious infection resulting from delayed appendectomy, suggesting that the decision to delay appendectomy for uncomplicated acute appendicitis can be made with low likelihood of major complications resulting from delayed surgery.

These findings suggest that for CT-diagnosed uncomplicated appendicitis, an initial trial of antibiotics is reasonable followed by elective appendectomy for patients who do not improve with antibiotics or present with recurrent appendicitis. Because patients with complicated appendicitis, with appendicoliths, children, and pregnant women were excluded from this study, the results do not apply to these groups.

Future studies are warranted that should focus both on early identification of complicated acute appendicitis patients needing surgery and to prospectively evaluate the optimal use of antibiotic treatment in patients with uncomplicated acute appendicitis.

The pitfalls of antibiotic treatment should also be addressed in future studies. Broad spectrum antibiotics can promote the emergence resistant organisms as well as Clostridium difficile infections. These potential adverse effects may tilt the balance towards performing appendectomy.

Furthermore, inclusion of greater number of patients is required in future studies to evaluate the ability of antibiotics to prevent pelvic abscesses as effectively as surgery.

These study has highlighted the need consider discarding routine appendectomy for patients with uncomplicated appendicitis. Because of the availability of precise diagnostic capabilities like CT and effective broad-spectrum antibiotics, appendectomy may be unnecessary for uncomplicated appendicitis.