Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

Abstract

Background This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis. Methods A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented. Results Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. −0.05 to 0.35)). Conclusions Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.

IL-5 Serum and Appendicular Lavage Fluid Concentrations Correlate with Eosinophilic Infiltration in the Appendicular Wall Supporting a Role for a Hypersensitivity Type I Reaction in Acute Appendicitis

“…In the beginning of this century, a strong trend to not operate on all the patients with appendicitis gained traction [ 10 , 25 , 26 , 27 ]. The analysis of the results of this policy is out of the scope of this paper.…”

Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review

“…However, the 2020 Jerusalem Guidelines suggest NOM as a first-line treatment for uncomplicated AA, with careful counseling regarding the possibility of failure in adults and children [ 55 ]. Recent evidence shows increased readmission rates, treatment failure, and complications with NOM [ 89 , 90 ]. While few studies have examined the quality of life (QOL) after either treatment, the CODA trial showed no significant difference between NOM and appendectomy [ 90 , 91 ].…”

“…Urgent surgery is recommended for cases of complicated appendicitis with generalized peritonitis. Laparoscopic appendectomy is generally recommended over open appendectomy due to its shorter length of stay, lower readmission rate, and lower overall complication rate [ 89 , 97 ]. Although there has been growing interest in alternative procedures such as laparoscopic single-incision appendectomy, endoscopic retrograde appendicitis therapy (ERAT), and natural orifice transluminal endoscopic surgery (NOTES), there are no current recommendations to support these procedures over conventional laparoscopic appendectomy [ 55 , 110 , 133 ].…”

Management of appendicitis: appendicectomy, antibiotic therapy, or both?

“…It is important to note that the earlier optimism regarding the benefit of antibiotic therapy for uncomplicated acute appendicitis was not demonstrated in Herrod et al . 30 meta-analysis of further large trials. They showed a primary antibiotic treatment efficacy of 63% at 1 year compared with an efficacy of 92% for appendicectomy.…”