The New “Standard of Care” for Appendicitis

Effectively, that is the question raised by this study – regarding antibiotics vs. surgery for acute, uncomplicated appendicitis.

This is a pragmatic, prospective study conducted in the pediatrics population at Nationwide Children’s Hospital.  The intervention and comparison were simple: qualifying patients with objectively mild appendicitis were offered a choice between hospitalization and intravenous antibiotics alone, or appendectomy with 12 hours.

And, as generally expected, not every patient choosing antibiotics successfully completed follow-up without crossover.  Of the 37 patients and families choosing antibiotics, 2 failed initial hospitalization, another 2 failed within 30 days, and 5 more failed within a year.  Median follow-up was 21 months at the time of article submission, and no further patients had undergone appendectomy.  Of 65 children undergoing surgery, 5 had post-operative complications, two of which were major (re-hospitalization, re-operation).

However, as I stated above, the question raised regarding antibiotics and appendicitis – is it now necessary it be discussed?  Have we reached a critical mass in the literature where all patients with suspected uncomplicated disease be offered antibiotics-only?  It is certainly unreasonable foundation for a complaint if an informed consent for surgical treatment of appendicitis did not include an antibiotics-only strategy as a legitimate alternative.  It was, in this cohort, much less disabling, in general, and substantially cheaper.

If not now – the not-to-distant future.

“Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis”

6 thoughts on “The New “Standard of Care” for Appendicitis”

  1. Ryan,

    Excellent post and great points. Are we at the point now when we need to offer medical management in uncomplicated appendicitis? I understand that the Europeans are perhaps ahead of us on this one.

    In my regional ED in Australia, I posed this question to our surgeons. In the end, the consensus was to stick with the knife. They feel that it is very much a minor surgery and medical therapy will fail about 1/3 of the time (a failure has been variable defined but generally means they have to get their appendix out anyway after some period of time.) At least they have been keeping up with the literature… but probably encouraged by our ED pushing the issue a bit. They just can't get rid of their knives.

    I guess the other question comes up; do we offer medial treatment before engaging the surgeons. This could open up a whole can of worms if they eventually have to get their appendix out and the surgeons are not happy about it.

    In the end, I think this will have to be a collaborative decision after discussion with the surgical team as they will be the ones to manage any complications, probably admit the patient for antibiotics, and operate on the "failures." It will be interesting to see how things change in the next 5-10 (or one hundred) years.

  2. ANd it is way easier surgery whith successful antibiotic therapy 😉 In 60% of cases.

    One problemis that not all papers sum "failure" or complications the same way .
    Maybe there should be a comparison of :
    – the sum of complications in each arm :
    * surgery needed after ATB failure or second surgery or intervention (abscess aspiration …) after initial surgery and other major complications.
    * length of stay in hospital
    * lost days of work / school

    One Scandinavian study used an antibiotic I don't remember (imipenem I think) but that we would never use as first line in an uncomplicated community acquired infection.

  3. I think it's important to point out that this study was very small- and because it was very small, there were important imbalances that came out in the outcomes. As pointed out in Skeptical Scalpel's blog,( ) AFTER the parents were allowed to pick whichever option they wanted, 2 patients who underwent operations were found to have gangrenous appendixes, and 4 had perforated. These patients had complicated courses, and would have done quite poorly if antibiotics alone had been tried. Had the parents of those 6 chosen the other option, the trial could have come out with a strongly negative result on the whole affair.

    Vamsi Aribindi

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