medwireNews: Antibiotic treatment of adults with acute appendicitis is not associated with an increased risk for complications relative to appendectomy and may allow patients to avoid the surgical procedure, shows a meta-analysis of individual patient data.
However, in patients with an appendicolith, initial antibiotic treatment increases the risk for complications versus appendectomy and may lead to step-up appendectomy within 1 year in almost 50% of cases.
The analysis included data for 2101 patients (60.5% men) with imaging-confirmed acute appendicitis who took part in six randomized controlled trials comparing antibiotics with appendectomy.
Marja Boermeester (University of Amsterdam, the Netherlands) and co-authors report in The Lancet Gastroenterology & Hepatology that after 1 year, 5.4% of 1050 patients randomly assigned to receive antibiotics had complications, which were defined and harmonized across the trials using the Clavien–Dindo classification.
Of note, appendectomy was not considered a complication of antibiotic treatment but was carried out during the first year of follow-up in 33.9% of patients given antibiotics. The surgery rate was 14.6% during the first 30 days after randomization.
The complication rate among the 1051 patients assigned to undergo appendectomy was 8.6% at 1 year and was not significantly different from that among people given antibiotics. The majority (97.1%) of patients assigned to appendectomy were operated on within 30 days, with an additional 0.4% undergoing the procedure later.
A subgroup analysis of 383 patients with an appendicolith at pre-interventional imaging showed that their risk for complications was a significant 2.8-fold higher with antibiotics than with appendectomy. Specifically, 15.0% of 193 patients in the antibiotics group had a complication compared with 6.3% of 190 patients in the appendectomy group.
Among the patients given antibiotics, 48.7% of those with an appendicolith underwent appendectomy within 1 year compared with 30.6% of those without an appendicolith.
Boermeester and co-authors note that previous studies have shown that “[f]rom a patient perspective, undergoing appendicectomy after either successful antibiotic therapy or due to primary unresponsiveness to antibiotics can understandably decrease patient satisfaction.”
They add, [h]owever, that “recent questionnaires show that most patients would be willing to try antibiotic treatment even at a considerable risk of future appendicectomy.”
The team says that this information highlights “the importance of providing patients with appendicitis with unbiased information on treatment options.”
In an accompanying comment, Adewale Adisa, from Obafemi Awolowo University in Ile-Ife, Nigeria, says that “evidence from this and previous studies suggests that antibiotics could be safe and effective in delaying appendicectomy when necessary, but unanswered questions remain as to whether to repeat antibiotics if symptoms recur and when to proceed to appendicectomy, because the delay does not always mean denial.”
medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2025 Springer Healthcare Ltd, part of the Springer Nature Group
Lancet Gastroenterol Hepatol 2025; doi:10.1016/S2468-1253(24)00349-2
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