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60% of adults treated with abx for acute appendicitis do not require appendectomy at 5 years
Clinical Question
What is the likelihood of a late recurrence of appendicitis in adults initially given antibiotic therapy for uncomplicated acute appendicitis?
Bottom line
This study found that more than 60% of adults who presented with uncomplicated appendicitis were successfully treated with antibiotics alone. Those patients who developed recurrent disease and required surgical intervention within 5 years did not experience any additional adverse outcomes related to the delay. Of the 257 patients initially randomized to receive antibiotic therapy, 70 underwent appendectomy within the first year, with 30 additional patients undergoing appendectomy between years 1 and 5. 1b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
These investigators are publishing 5-year follow-up data from a study that compared immediate surgery to antibiotic therapy in 530 adults aged 18 years to 60 years (Salminen P, et al. JAMA 2015;313(23):2340-48). The original trial reported after 1 year approximately 75% of adults treated initially with antibiotics did not require appendectomy. After the first-year follow-up, the investigators conducted telephone interviews 3 to 5 years after the intervention and performed a search of hospital records for those patients who could not be reached. Using intention-to-treat analysis, the cumulative incidence of acute appendicitis recurrence in the antibiotic group was 39.5% (95% CI 33.1% - 45.3%) at 5 years. Of the 85 patients in the antibiotic group who underwent appendectomy for presumed recurrence, no appendicitis was found in 7 patients, resulting in a true recurrence rate of 32.4%. The overall complication rate was similar between surgically treated patients who were initially randomized to the antibiotic group and those randomized to the immediate appendectomy group. The overall complication rate was significantly lower, however, in the subgroup of patients who underwent laparoscopic appendectomy (7.5%) than in the open appendectomy group. Thus, the potential benefits of antibiotics versus immediate surgery may be reduced with the laparoscopic approach.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Validate these results match bigger studies are needed and I know, are on the way. There is no mention of stratification of patients according to their risk category. A huge point is a potential for missing malignancy, carcinoid and adenocarcinoma. I do have a personal case like that and trust me, it is incredibly distressing!
It is important to know that treated with abx for acute appendicitis do not require appendectomy in adult . It is very good finding . We can use this information to treat adult with appendicitis.
I have been offering IV antibiotics for treatment for acute appendicitis, but this article is VERY helpful to have good stats to discuss with patients.
Seems there is conflicting evidence about this lately.
good poem
40% treatment failure rate with a second trip to the ER and likely second admission to hospital with need for antibiotics - hopefully this will not become standard of care.
The comments comparing results with open surgery and laparoscopic surgery would need a bit of clarification too. An open appendectomy via a 2cm incision with discharge home the same day with a low rate of incisional hernia and no need for narcotic analgesic is quite different from a laparoscopic converted to open case or an open appendectomy in an obese patient. There are just too many biases in making conclusions about open and laparoscopic procedures.
The useful points here are that there is some idea as to the effectiveness of antibiotics with acute appendicitis and that when recurrence occurs or treatment fails, that there is no adverse consequence when the surgeon is called.
I am glad that my appendix is already out.