From the Guidelines
Conservative treatment of acute appendicitis is a viable alternative to surgery in select patients, particularly those with uncomplicated appendicitis, and can be achieved with antibiotics as the primary treatment. The recommended approach involves antibiotics as the primary treatment, typically starting with intravenous antibiotics for 1-2 days followed by oral antibiotics for a total of 7-10 days, as suggested by the 2020 update of the WSES Jerusalem guidelines 1. Common antibiotic regimens include a combination of a beta-lactam (such as amoxicillin-clavulanate 875/125 mg twice daily or cefoxitin 2g every 6-8 hours) plus metronidazole 500 mg three times daily for anaerobic coverage. For patients with penicillin allergies, fluoroquinolones (such as ciprofloxacin 500 mg twice daily) with metronidazole can be used.
Key Considerations
- This approach is most appropriate for uncomplicated appendicitis, defined as inflammation without perforation, abscess, or peritonitis.
- Evidence shows that approximately 70-80% of patients with uncomplicated appendicitis can avoid surgery with antibiotic treatment, though 20-30% may experience recurrence within one year and eventually require appendectomy, as reported in a meta-analysis by Kessler et al. 1.
- Conservative management is particularly suitable for patients with comorbidities that increase surgical risks, the elderly, or those with strong preferences to avoid surgery.
- Close monitoring is essential during treatment, with clear instructions for patients to seek immediate medical attention if symptoms worsen, as this may indicate treatment failure requiring surgical intervention.
Recent Guidelines
The 2021 WSES position paper on the management of surgical patients in the emergency setting during the COVID-19 pandemic also supports the use of conservative treatment for uncomplicated acute appendicitis, with an "antibiotic first" policy as a safe tool to avoid surgery and postpone it, eventually, to treat a recurrence 1.
Patient Selection
Patient selection is crucial, and the presence of an appendicolith is associated with high failure rates of non-operative management, as reported by Mahida et al. and Tanaka et al. 1. Therefore, non-operative management should be considered on a case-by-case basis, according to the WSES guidelines, and patients with evidence of an appendicolith on imaging may not be ideal candidates for conservative treatment.
From the Research
Overview of Conservative Treatment for Acute Appendicitis
- Acute appendicitis is a common emergency abdominal disease that can be treated with conservative methods using antibiotics for uncomplicated cases 2, 3, 4, 5, 6.
- The efficacy of conservative treatment for uncomplicated appendicitis is known, but its efficacy for complicated appendicitis remains unknown, along with risk factors for the conservative treatment of appendicitis 2.
Evidence for Conservative Treatment
- A study published in the World Journal of Gastrointestinal Surgery in 2024 found that 89.7% of patients improved with conservative treatment, and significant predictors of resistance to conservative treatment included body temperature ≥ 37.3 °C, appendicolith, and Douglas sinus fluid visible on computed tomography (CT) 2.
- Another study published in JAMA in 2021 suggested that broad-spectrum antibiotics can successfully treat uncomplicated acute appendicitis in approximately 70% of patients, but specific imaging findings on CT can identify patients for whom an antibiotics-first management strategy is more likely to fail 3.
- A study published in the World Journal of Surgery in 2012 found that 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 4.
- A review published in Prescrire International in 2014 found that antibiotic therapy was associated with fewer immediate complications than surgery, but more subsequent failures, and that the overall incidence of complications of appendicitis was 25% in the immediate appendectomy group versus 18% in the antibiotic group 5.
Current Management of Acute Appendicitis
- A review published in The Journal of Trauma and Acute Care Surgery in 2025 outlined the current principles of diagnosis, imaging, and treatment of acute appendicitis, including the use of antibiotics for uncomplicated cases and timely surgical intervention for complicated cases 6.
- The review also noted that certain patient populations, such as pregnant patients and immunosuppressed patients, should undergo timely surgical intervention to decrease the risk of complications 6.