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Antibiotics offer a safe alternative to surgery for most adults with acute appendicitis. But, those with an appendicolith have higher complication risks and a greater chance of needing surgery.
Can antibiotics replace surgery for appendicitis? A new meta-analysis suggests they might—at least for some patients!
Researchers analyzed data from 6 randomized controlled trials (RCTs), including 2,101 patients (1,050 treated with antibiotics and 1,051 who underwent appendicectomy). The study aimed to standardize outcome definitions across trials and scrutinize the long-term safety and effectiveness of antibiotics compared to surgery for imaging-confirmed acute appendicitis in adults. An extensive search of databases (Cochrane, Embase, PubMed) identified studies with 1-year follow-up data on complications.
Eligible studies shared validated patient data, which were examined via a mixed-effects regression model. The key outcome ascertained was the 1-year complication rate, classified with the aid of Clavien–Dindo system. The rate of appendicectomy within 1 year was the key secondary outcome, though it was not classified as a complication in patients receiving antibiotic treatment. Outcomes were monitored separately for participants with and without an appendicolith (calcified deposits within the appendix).
At 1 year, the complication rates were lower in those treated with antibiotics as opposed to those who underwent appendicectomy. Most patients in the surgery group had their appendix removed, while a significant portion of those in the antibiotics group avoided surgery. However, patients with an appendicolith had a higher risk of complications with antibiotic treatment and were more likely to require appendicectomy within a year compared to those without an appendicolith, as shown in Table 1:
The findings support antibiotics as a feasible alternative to surgery for most patients (around two-thirds) with acute appendicitis, particularly those without an appendicolith. However, for patients with an appendicolith, surgery may be the preferred option due to the higher risk of complications and the increased likelihood of requiring surgery later.
Given the variability in outcomes, shared decision-making is crucial. Clinicians should discuss the benefits and risks of both treatment approaches with patients, considering individual factors such as imaging findings and patient preferences. This study reinforces the growing evidence that non-operative care of acute appendicitis can be beneficial but requires prudent patient selection.
The Lancet Gastroenterology & Hepatology
Antibiotic treatment versus appendicectomy for acute appendicitis in adults: an individual patient data meta-analysis
Jochem C G Scheijmans et al.
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