Antibiotics May Be Enough for Appendicitis

For uncomplicated appendicitis, using antibiotics first may preclude the need to remove the appendix and reduce complications, a meta-analysis suggested.

In a meta-analysis of four randomized trials, initial treatment with antibiotics prevented the need for appendectomy in 63% of patients, according to Dileep Lobo, DM, of Nottingham University Hospitals in England, and colleagues.

In addition, first-line antibiotic treatment was associated with a relative 31% lower risk of complications compared with appendectomy (18% versus 25%; RR 0.69, 95% CI 0.54 to 0.89), the researchers reported online inBMJ.

Based on the results, they said that "initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis."

"Given the increase in nonperforated appendicitis diagnosed with more frequent use of computed tomography and laparoscopy, a careful 'wait, watch, and treat' policy may be adopted in those patients considered to have uncomplicated appendicitis or in whom the diagnosis is uncertain, as in these patients correct diagnosis rather than an early appendectomy is the key," they wrote.

They added that early appendectomy remains the gold standard for patients with clear signs of perforation or peritonitis.

For more than a century, appendectomy has been the go-to treatment for appendicitis based on the belief that the disease often progresses from uncomplicated appendicitis to perforation.

Only 20% of patients present with complicated disease, however, and the preferred use of appendectomy has been called into question by recent reports of less morbidity with an antibiotic-first approach.

To compare the two approaches, Lobo and colleagues performed a meta-analysis of four randomized controlled trials with a total of 900 adult patients with suspected uncomplicated acute appendicitis. Routine radiological confirmation of the diagnosis was not used in all of the studies.

The primary outcome was the rate of complications, which were defined as perforated or gangrenous appendicitis or peritonitis and wound infection (for patients who failed antibiotics and underwent surgery) in the antibiotic group and as perforated appendicitis or peritonitis and wound infection in the appendectomy group.

Initial use of antibiotics was associated with a significant reduction in complications, even after excluding the study that had a large number of patients who crossed over from the antibiotic group to the appendectomy group after randomization (12% versus 19%; RR 0.61, 95% CI 0.40 to 0.92).

Overall, 20% of the patients in the antibiotic group had an appendectomy after readmission to the hospital within one year, and of those, nine had perforated appendicitis and four had gangrenous disease. The overall risk of perforated or gangrenous appendicitis in the antibiotic group was 7.4%.

There were no differences between the two groups in treatment efficacy, length of stay, or the risk of developing complicated appendicitis.

In an accompanying editorial, Olaf Bakker, MD, of the University Medical Center Utrecht in the Netherlands, said that, at first glance, the findings appear to contradict the accepted dogma of prompt appendectomy.

He noted, however, that using antibiotics for initial treatment has some disadvantages, including the need for delayed appendectomy in some patients with persistent symptoms, the 20% chance of recurrence within the first year, which may be unacceptable, and the need to perform CT in all patients to rule out perforated appendicitis before starting antibiotics.

On the other hand, appendectomy also has drawbacks, including the need for general anesthesia and the risk of procedure-related complications like wound infection.

The researchers "are appropriately circumspect in concluding that conservative treatment merits consideration as a primary treatment option," Bakker wrote. "However, until more convincing studies and longer-term results are published, appendectomy will probably continue to be used for uncomplicated appendicitis."

Source reference:
Varadhan K, et al "Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: a meta-analysis of randomized controlled trials" BMJ 2012; DOI: 10.1136/bmj.e2156.

Tomado de: medpagetoday.com . By Todd Neale, Senior Staff Writer .Published: April 05, 2012