Antibiotics Are a Reasonable Treatment Option for Uncomplicated Appendicitis
In a small observational study, antibiotics were safe and efficacious but had a short-term failure rate of 12%.
Recent research suggests that antibiotic therapy is a reasonable alternative to operative management for uncomplicated appendicitis. In a prospective, observational study conducted in Italy, investigators assessed the safety and efficacy of observation and amoxicillin/clavulanate in 159 patients aged >14 years who presented to the emergency department in 2010 with right lower quadrant pain and presumed appendicitis (based on Alvarado score, appendicitis inflammatory response score, or both), but without peritonitis. If pain was unchanged or worse on day 5, patients underwent appendectomy; if symptoms recurred during the study period, patients were offered antibiotics or operative management. Telephone or e-mail follow-up continued for 2 years.
Imaging was diagnostic or suggestive of appendicitis in 76% of ultrasounds (88 of 116) and 78% of computed tomography scans (21 of 27). Mean hospital length of stay and sick leave were 0.4 and 5.8 days, respectively. Of 19 patients (12%) who had failure of nonoperative management and underwent surgery, 2 were diagnosed with tubo-ovarian abscess intraoperatively, 6 developed surgical-site infections, and 1 had an intra-abdominal abscess. By 2 years, 22 patients (14%) had suffered a recurrence; 14 (64%) of them were treated successfully with antibiotics.
This small study demonstrates the safety and efficacy of antibiotic therapy for uncomplicated appendicitis. If trials continue to show similar complication rates between operative and nonoperative management, I suspect we will see more surgeons choosing a trial of antibiotic therapy for this condition. We as emergency providers will have to work closely with our surgical teams to properly select patients with uncomplicated appendicitis (likely after confirmatory diagnostic imaging) who would be reasonable candidates for nonoperative management.
Cheryl Lynn Horton, MD reviewing Di Saverio S et al. Ann Surg 2014 Mar 18.
Di Saverio S et al. The NOTA Study (Non Operative Treatment for Acute Appendicitis): Prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg 2014 Mar 18; [e-pub ahead of print].