Although results from a new JAMA study showed that antibiotic treatment for uncomplicated appendicitis did not meet a prespecified level of effectiveness compared with appendectomy, an accompanying editorial suggests that initial antibiotic therapy could still be an option for many patients.
Paulina Salminen, MD, PhD, of Turku University Hospital in Turku, Finland, and colleagues designed the Appendicitis Acuta (APPAC) clinical trial as a multicenter, open-label, noninferiority randomized study from November 2009 to June 2012 in Finland to compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis. The researchers randomly assigned 530 patients with uncomplicated appendicitis confirmed by computed tomography (CT) to antibiotic therapy for 10 days (intravenous ertapenem 1g/day for 3 days, followed by 7 days of oral levofloxacin 500mg/once daily and metronidazole 500mg 3 times daily) or standard open appendectomy. The primary endpoint for the antibiotics group was hospital discharge without the need for surgery and no recurrent appendicitis over a one-year follow-up period; for the surgery arm, it was the successful completion of an appendectomy.
A success rate of 99.6% was achieved with standard appendectomy while 72.7% of those receiving antibiotics did not require surgery during the one-year follow-up. Only 10% of patients who did require surgery after treatment with antibiotics had complicated acute appendicitis and 7.1% did not have appendicitis but received appendectomy for suspected recurrence. With the prespecified noninferiority margin of 24%, the researchers were unable to demonstrate noninferiority of antibiotic treatment compared to appendectomy. However, no major complications such as intra-abdominal abscesses were detected with delayed appendectomy in patients receiving antibiotics.
In an accompanying editorial Edward Livingston, MD, and Corrine Vons, MD, PhD, added that an initial trial of antibiotics could be feasible for patients with CT-diagnosed uncomplicated appendicitis, followed by elective appendectomy for those who do not improve with antibiotics or present with recurrent appendicitis.
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