Study Supports Antibiotic-Only Approach to Treating Uncomplicated Acute Appendicitis

A new study by investigators in Finland supports the use of antibiotic treatment alone as an alternative to surgery for cases of uncomplicated acute appendicitis.

Appendicitis is an infection of the appendix, a small organ in the lower right area of the abdomen. The appendix is attached to the large intestine but has no known function. According to the American College of Surgeons, the opening of the appendix can become blocked due to illness, thick mucus, hard stool, or a tumor, and that blockage can allow bacteria to grow and cause an infection. When the appendix ruptures and bursts, stool and bacteria can be released and cause an infection of the entire abdomen, referred to as peritonitis. Symptoms of appendicitis include pain in the lower right area of the abdomen, loss of appetite, low fever, nausea or vomiting, and diarrhea or constipation.

More than 5% of the population in the United States develop appendicitis at some point, according to the National Institutes of Health (NIH), and studies have typically supported appendectomy—the surgical removal of the appendix—as the gold standard of treatment for uncomplicated acute appendicitis. Appendectomy prevents peritonitis but complications such as abscess, wound infection, and hernia at incision can occur. In a new study published in the Journal of the American Medical Association, a team of investigators at the University of Turku in Finland says that short-term results support the use of antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis.

The paper details the results of the 5-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter randomized clinical trial. The initial trial was conducted from November 2009 to June 2012, with follow-up concluding in September 2017. It included 530 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis, who were randomized to undergo either an appendectomy or receive antibiotic therapy. The open appendectomy group included 273 patients, while 257 patients received intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.

During the follow-up period, 70 of the patients in the antibiotic treatment group underwent appendectomy within the first year, while another 30 patients in the group underwent appendectomy between 1 and 5 years. Overall, patients initially treated with antibiotics for uncomplicated acute appendicitis had a 39.1% likelihood of late recurrence within 5 years. In addition, the appendectomy group saw an overall complication rate of 24.4%, higher than the overall complication rate of 6.5% in the antibiotic group. The findings, the authors say, suggest that initial treatment with antibiotics may be a feasible alternative to surgery, which leads to more days of sick leave.

In an interview with Contagion^®, first author Paulina Salminen, MD, says that only recently has there been available knowledge about the fact that antibiotic therapy alone is an effective, feasible, and safe treatment option for patients with uncomplicated acute appendicitis.

“We need to change the line of thinking that has persisted over a hundred years that acute appendicitis always progresses to perforation and thus always requires emergency appendectomy,” Dr. Salminen said, pointing out that there are 2 different forms of acute appendicitis. About 70% to 80% of cases are uncomplicated, while the 20% to 30% of patients with complicated appendicitis almost always need surgery. “However, based on our current 5-year follow-up results of the APPAC trial, we also know that at long-term antibiotic therapy is a feasible option and an alternative to surgery in patients with uncomplicated acute appendicitis.”

Dr. Salminen explained that prior to choosing the right treatment option for a patient, proper use of clinical and radiological criteria is needed for the differential diagnosis between uncomplicated and complicated acute appendicitis, along with surgical evaluation of the patient’s status as well as insight into patient preference, which also plays an important part in choosing the optimal treatment for each patient.

“Patients, emergency physicians, and surgeons are becoming aware of this antibiotics-alone treatment option and this big change in the mindset of patients and doctors has in my opinion already started,” Dr. Salminen said. “Acute appendicitis is the most common indication for emergency surgery globally and we naturally need a lot of future studies assessing these treatment options.”