Antibiotics for Acute Uncomplicated Appendicitis in Children

A recent meta-analysis study (L Huang et al. JAMA Pediatr 2017; 17: 426-34 -thanks to Ben Gold for this reference) indicates that antibiotcis can be effective as treatment for acute uncomplicated appendicitis, particularly if no appendolith is present.

From the abstract:

Abstract

IMPORTANCE:

Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial.

OBJECTIVE:

To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients.

STUDY SELECTION:

Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days.

RESULTS:

A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%).

CONCLUSIONS AND RELEVANCE:

This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.

From a AHC Media synopsis of article:Although antibiotic treatment of acute appendicitis appears effective in many cases, there is a nearly nine-fold higher risk of treatment failure compared with appendectomy, with 26.8% of patients in the antibiotic treatment group requiring interval appendectomy.

My take: My opinion is that surgery is appropriate as first-line treatment for  acute uncomplicated appendicitis.

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