Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review

Abstract

BACKGROUND Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist. METHODS PUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS Thirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success. CONCLUSION While further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management. LEVEL OF EVIDENCE Systematic review, level II.

Current Approach to Acute Apendicitis: A Case Report

“…Devido a lacunas de evidência, não está recomendado o tratamento antibiótico rotineiramente a fim de substituir cirurgia. (Talan DA et al, 2018).…”

“…Essa abordagem apresentou taxas relativamente baixas (<10%) de recorrência de apendicite ou abscesso após tratamento conservador inicial. Meta-análises constataram que tratamento conservador está associado com complicações semelhantes ou menores em comparação com cirurgia inicial e uma diretriz recente agora reconhece que essa modalidade pode ser bemsucedida para pacientes selecionados que desejam evitar a cirurgia precocemente (Talan DA et al, 2018).…”

“…As taxas de resposta a antibióticos em ensaios utilizando esses medicamentos foram altos, 88% a 100%, com duração de 7-10 dias. [Di Saverio et al, 2016;Talan DA et al, 2018) Essa abordagem não invasiva inicialmente decorre da preocupação devido a anatomia distorcida, podendo levar a lesões de estruturas intra-abdominais circunvizinhas e possíveis possibilidades de ressecção ileocólica ou hemicoletomia. (Al-Kurd et al, 2018) Existem três razões principais para lançar mão de investigação complementar no contexto da massa do apêndice: em primeiro lugar avaliar a resposta da massa / abscesso ao tratamento conservador segundo, para verificar se existe algum fecalito, que alguns autores consideram como fator isolado de recorrência, e terceiro, para excluir outros diagnósticos.…”

Cancer of the appendix and nonoperative treatment of appendicitis shared decision making

“…The peak incidence of appendicitis is in the 10 to 30 year age range, when cancer is relatively uncommon. Further, by examining the entry criteria of 34 studies of nonoperative treatment of patients with uncomplicated appendicitis, 5 we find that nonoperative treatment is cancer prevalence among patients with imaging-identified appendiceal abscess, predominantly mucinous neoplasms and adenocarcinomas; all patients were more than 40 years of age. 7 Younger patients and those with uncomplicated appendicitis who are candidates for nonoperative treatment are generally at lower cancer risk and, additionally, appear to have less aggressive tumor types than older patients with complicated disease should detection be delayed.…”

“…9 Among 2944 antibiotic-treated patients in published trials, who ranged in age from 1 to 92 years, no related deaths have been reported. 5 Most experience with nonoperative treatment is in those 5 to 50 years of age, but with further study, we should learn more about how the treatment options compare in terms of standard clinical outcomes among older populations.…”