Abstract
Background
Randomized studies have indicated that acute appendicitis may be treated by antibiotics without the need of surgery. However, concerns have been raised about selection bias of patients in such studies. Therefore, the present study was aimed to validate previous findings in randomized studies by a full-scale population-based application.
Methods
All patients with acute appendicitis at Sahlgrenska University Hospital (May 2009 and February 2010) were offered intravenous piperacillin plus tazobactam according to our previous experience, followed by 9 days out-hospital oral ciprofloxacin plus metronidazole. Endpoints were treatment efficacy and complications. Efficient antibiotic treatment was defined as recovery without the need of surgery beyond 1 year of follow-up.
Results
A total of 558 consecutive patients were hospitalized and treated due to acute appendicitis. Seventy-nine percent (n = 442) received antibiotics as first-line therapy and 20 % (n = 111) had primary surgery as the second-line therapy. Seventy-seven percent of patients on primary antibiotics recovered while 23 % (n = 100) had subsequent appendectomy due to failed initial treatment on antibiotics. Thirty-eight patients (11 %) of the 342 had experienced recurrent appendicitis at 1-year follow-up. Primary antibiotic treatment had fewer complications compared to primary surgery.
Conclusions
This population-based study confirms previous results of randomized studies. Antibiotic treatment can be offered as the first-line therapy to a majority of unselected patients with acute appendicitis without medical drawbacks other than the unknown risk for long-term relapse, which must be weighed against the unpredicted but well-known risk for serious major complications following surgical intervention.
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References
Hennelly KE, Bachur R (2011) Appendicitis update. Curr Opin Pediatr 23(3):281–285
D’Souza N (2011) Appendicitis. Clin Evid 7 Jan 2011 http://clinicalevidence.bmj.com
Fitzmaurice GJ, McWilliams B, Hurreiz H, Epanomeritakis E (2011) Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence. Can J Surg 54(3):6610
Mason RJ (2008) Surgery for appendicitis: is it necessary? Surg Infect (Larchmt) 9(4):481–488
Vons C (2009) Can acute appendicitis be treated by antibiotics and in what conditions? J Chir (Paris) 146(Spec No 1):17–21
Andersson RE, Petzold MG (2007) Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and meta-analysis. Ann Surg 246(5):741–748
Coldrey E (1959) Five years of conservative treatment of acute appendicitis. J Inter Coll Surg 32:255–259
Styrud J, Eriksson S, Nilsson I et al (2006) Appendectomy versus antibiotic treatment in acute appendicitis: a prospective multicenter randomized controlled trial. World J Surg 30(6):1033–1037. doi:10.1007/s00268-005-0304-6
Hansson J, Korner U, Khorram-Manesh A et al (2009) Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 96(5):473–481
Malik AA, Bari SU (2009) Conservative management of acute appendicitis. J Gastrointest Surg 13(5):966–970
Vons C, Barry C, Maitre S et al (2011) Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 377(9777):1573–1579
Andersen BR, Kallehave FL, Andersen HK (2005) Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev (3):CD001439
Andersson MN, Andersson RE (2011) Causes of short-term mortality after appendectomy: a population-based case-controlled study. Ann Surg 254(1):103–107
Fike FB, Mortellaro VE, Juang D et al (2011) The impact of postoperative abscess formation in perforated appendicitis. J Surg Res 170(1):24–26
Ansaloni L, Catena F, Coccolini F et al (2011) Surgery versus conservative antibiotic treatment in acute appendicitis: a systematic review and meta-analysis of randomized controlled trials. Dig Surg 28(3):210–221
Suh SW, Choi YS, Park JM et al (2011) Clinical factors for distinguishing perforated from nonperforated appendicitis: a comparison using multidetector computed tomography in 528 laparoscopic appendectomies. Surg Laparosc Endosc Percutan Tech 21(2):72–75
Andersson RE (2004) Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 91(1):28–37
Wijetunga R, Doust B, Bigg-Wither G (2003) The CT diagnosis of acute appendicitis. Semin Ultrasound CT MR 24(2):101–106
Lai V, Chan WC, Lau HY et al (2012) Diagnostic power of various computed tomography signs in diagnosing acute appendicitis. Clin Imaging 36(1):29–34
Wilms IM, de Hoog DE, de Visser DC, Janzing HM (2011) Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev (11):CD008359
Tingstedt B, Johansson J, Nehez L, Andersson R (2004) Late abdominal complaints after appendectomy—readmissions during long-term follow-up. Dig Surg 21(1):23–27
Augustin T, Cagir B, Vandermeer TJ (2011) Characteristics of perforated appendicitis: effect of delay is confounded by age and gender. J Gastrointest Surg 15(7):1223–1231
Hall AB, Freeman T, Banks S (2011) Is it safe? Appendectomies at night at a low-volume center. J Surg Educ 68(3):199–201
Andersson RE (2001) Small bowel obstruction after appendicectomy. Br J Surg 88(10):1387–1391
Lamps LW (2004) Appendicitis and infections of the appendix. Semin Diagn Pathol 21(2):86–97
Bennion RS, Baron EJ, Thompson JE Jr et al (1990) The bacteriology of gangrenous and perforated appendicitis—revisited. Ann Surg 211(2):165–171
Acknowledgments
This work was supported by grants from Region Västra Götaland, Gothenburg Medical Society, the Swedish government (LUA-ALF).
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Hansson, J., Körner, U., Ludwigs, K. et al. Antibiotics as First-line Therapy for Acute Appendicitis: Evidence for a Change in Clinical Practice. World J Surg 36, 2028–2036 (2012). https://doi.org/10.1007/s00268-012-1641-x
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DOI: https://doi.org/10.1007/s00268-012-1641-x