Antibiotic therapy compared to appendectomy in the treatment of acute appendicitis.

Wilms IMHA, de Hoog DENM, de Visser DC, Janzing HMJ

Published Online:

November 9, 2011

Acute appendicitis is one of the most common surgical causes of acute abdominal pain. Appendectomy is the treatment of choice, however surgical complications are inherent to operative treatment. Recent research on primary antibiotic therapy (without surgery) reported good results.

This review investigates whether antibiotic therapy is as effective as appendectomy in patients with uncomplicated appendicitis. Included endpoints were cure within two weeks without major complications (including recurrent appendicitis) within one year, major and minor complications and duration of hospital stay. We could not conclude whether antibiotic treatment is or is not inferior to appendectomy. Because of the low to moderate quality of the trials, appendectomy remains the standard treatment for acute appendicitis.

Abstract (click to read)

Background:

Acute appendicitis is one of the most common causes of acute abdominal pain. Present day treatment of choice for acute appendicitis is appendectomy, however complications are inherent to operative treatment. Though surgical appendectomy remains the standard treatment, several investigators have investigated conservative antibiotic treatment of acute appendicitis and reported good results.

Objectives:

Is antibiotic treatment as effective as surgical appendectomy (laparoscopic or open) in patients with acute appendicitis on recovery within two weeks, without major complications (including recurrence) within one year?

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 6, 2011); MEDLINE (until June 2011); EMBASE (until June 2011); Prospective Trial Registers (June 2011) and reference lists of articles.

Selection criteria:

Randomised and quasi-randomised clinical trials (RCT and qRCT) comparing antibiotic treatment with appendectomy in patients with suspected appendicitis were included. Excluded were studies which primarily focused on the complications of acute appendicitis.

Data collection and analysis:

Two authors independently assessed trial quality and extracted data. The review authors contacted the trial authors for additional information if required. Statistical analysis was carried out using Review Manager and MetaAnalyst. A non-inferiority analysis was performed, comparing antibiotic treatment (ABT) to the gold standard (appendectomy). By consensus, a 20% margin of non-inferiority was considered clinically relevant.

Main results:

Five RCT's (901 patients) were assessed. In total 73.4% (95% CI 62.7 to 81.9) of patients who were treated with antibiotics and 97.4 (95% CI 94.4 to 98.8) patients who directly got an appendectomy were cured within two weeks without major complications (including recurrence) within one year. The lower 95% CI was 15.2% below the 20% margin for the primary outcome.

Authors' conclusions:

The upper bound of the 95% CI of ABT for cure within two weeks without major complications crosses the 20% margin of appendectomy, so the outcome is inconclusive. Also the quality of the studies was low to moderate, for that reason the results should be interpret with caution and definite conclusions cannot be made. Therefore we conclude that appendectomy remains the standard treatment for acute appendicitis. Antibiotic treatment might be used as an alternative treatment in a good quality RCT or in specific patients or conditions were surgery is contraindicated.

This record should be cited as:

Wilms IMHA, de Hoog DENM, de Visser DC, Janzing HMJ. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD008359. DOI: 10.1002/14651858.CD008359.pub2

Assessed as up to date:

October 4, 2011

Find the research

Get full text at The Cochrane Library

Primary Review Group:

Colorectal Cancer Group

Health topics:

Gastroenterology > Non-neoplastic disease of the small & large bowel > Appendiceal diseases

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Antibiotic therapy compared to appendectomy in the treatment of acute appendicitis.

More like this

Copyright © 2012 - The Cochrane Collaboration