Clinical Question

Can children with appendicitis be treated with antibiotics instead of surgery?

Bottom Line

Antibiotic treatment appears to be effective for children with uncomplicated appendicitis without evidence of perforation or rupture, with 97% of children discharged without surgery. Approximately one in seven children will eventually have recurrence and require surgery. A couple of days of intravenous antibiotics is an option before surgery. (Level of Evidence = 2a)

Synopsis

These researchers assembled studies that evaluated antibiotic use in the treatment of children with acute uncomplicated appendicitis (i.e., without perforation or rupture, or evidence of an abscess or mass). Two investigators independently searched three databases, including Cochrane Central, as well as reference lists, to identify all English-language studies that evaluated antibiotic treatment. Two authors independently extracted the data and evaluated its quality. All but one of the 10 studies (N = 766 children) were observational; four of the studies did not have a comparison group. Antibiotic treatment in these studies was usually intravenous for 48 hours, followed by oral treatment for an additional three to five days. Antibiotic treatment was effective in resolving the infection without the need for appendectomy during the initial hospitalization in 396 of 413 children (97% of children; 95% confidence interval, 96% to 99%). Over prolonged follow-up (eight weeks to four years), appendicitis occurred in 14% (95% confidence interval, 7% to 21%), but there was pronounced heterogeneity among the studies. Complications occurred similarly in children treated with surgery or with antibiotics. The studies are of low quality, for the most part, and it is time for a large randomized study (as has been done in adults: World J Surg. 2016;40(10):2305–2318). Still, if these were the data used to evaluate surgery as the first-line treatment for appendicitis, we would never have instituted it.

Study design: Meta-analysis (other)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Reference: Georgiou R, Eaton S, Stanton MP, Pierro A, Hall NJ. Efficacy and safety of nonoperative treatment for acute appendicitis: a meta-analysis. Pediatrics. 2017;139(3):e20163003.