From the Guidelines
Antibiotics are a viable treatment option for uncomplicated appendicitis, with a recommended course of 7-10 days, starting with intravenous antibiotics for 1-2 days followed by oral antibiotics. The use of antibiotics for uncomplicated appendicitis has been supported by recent studies, including the 2020 update of the WSES Jerusalem guidelines 1. According to the guidelines, the empiric antibiotic regimens for non-critically ill patients with community-acquired intra-abdominal infections include Amoxicillin/clavulanate 1.2–2.2 g 6-hourly or ceftriazone 2 g 24-hourly + metronidazole 500 mg 6-hourly 1. A recent meta-analysis by Harnoss et al. reported a recurrence rate of symptoms within 1 year of 27.4% following antibiotic-first treatment 1. However, the APPAC III multicenter, double-blind, placebo-controlled, superiority RCT comparing antibiotic therapy with placebo in the treatment of CT scan-confirmed uncomplicated AA is currently in its enrollment phase, aiming to evaluate the role of antibiotics in the resolution of the disease 1. Some key points to consider when using antibiotics for uncomplicated appendicitis include:
- Careful patient selection, excluding those with gangrenous AA, abscesses, and diffuse peritonitis 1
- The presence of an appendicolith as an independent prognostic risk factor for treatment failure in NOM of uncomplicated AA 1
- The potential for recurrence, with a risk of up to 39% after 5 years 1
- The importance of patient awareness and education on the risks and benefits of antibiotic treatment for uncomplicated appendicitis 1. Overall, the use of antibiotics for uncomplicated appendicitis can be a safe and effective treatment option, but it requires careful patient selection and consideration of the potential risks and benefits.
From the Research
Antibiotics for Uncomplicated Appendicitis
- Antibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, with treatment success rates greater than 65% in both oral and intravenous antibiotic groups 2.
- A review of the literature found that antibiotic therapy was associated with fewer immediate complications than surgery, but more subsequent failures, with 63% of patients treated with antibiotics being asymptomatic and having no complications or recurrences after one year 3.
- Broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, have been shown to successfully treat uncomplicated acute appendicitis in approximately 70% of patients 4.
Indications for Antibiotic Therapy
- Antibiotic therapy may be considered as first-line therapy in patients with uncomplicated appendicitis, especially those who are unfit for surgery or have a low risk of complications 4, 5.
- Specific imaging findings on computed tomography (CT), such as appendiceal dilatation or presence of appendicoliths, may identify patients for whom an antibiotics-first management strategy is more likely to fail 4.
- Patients with high-risk CT findings, such as appendicolith, mass effect, or a dilated appendix, may be recommended for surgical management 4.
Comparison of Antibiotic Regimens
- A randomized clinical trial compared oral moxifloxacin with intravenous ertapenem followed by oral levofloxacin and metronidazole, and found that both regimens had treatment success rates greater than 65%, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics 2.
- Another study found that primary antibiotic treatment with intravenous piperacillin plus tazobactam, followed by oral ciprofloxacin plus metronidazole, was effective in 77% of patients with acute appendicitis, with fewer complications compared to primary surgery 5.