Antibiotics versus surgery for uncomplicated acute appendicitis

The authors of this recent paper compared the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis using a meta-analysis of randomised controlled trials.

They chose randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations. The interventions were antibiotic treatment versus appendicectomy.

The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions.

Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at 1 year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy. A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy. Of the 65 (20%) patients who had appendicectomy after readmission, 9 had perforated appendicitis and 4 had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis.

The conclusion was that antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.

Varadhan KK, Neal KR, Lobo DN. BMJ

012;344:e2156.