What is the landmark trial that justifies conservative management for uncomplicated acute appendicitis?

From the Guidelines

The landmark trial that justifies conservative management for uncomplicated appendicitis is the APPAC (Appendicitis Acuta) trial. This Finnish randomized clinical trial, published in 2015, compared antibiotic therapy to appendectomy for uncomplicated appendicitis. The study demonstrated that approximately 73% of patients with uncomplicated appendicitis could be successfully treated with antibiotics alone, avoiding surgery. The antibiotic regimen used was intravenous ertapenem 1g daily for 3 days, followed by oral levofloxacin 500mg daily plus metronidazole 500mg three times daily for 7 days. The trial showed that while some patients (about 27%) eventually required appendectomy within one year, most could avoid surgery entirely. This challenged the century-old standard that appendicitis always requires surgical intervention. The APPAC trial's significance lies in providing evidence that antibiotics can be a safe first-line treatment option for selected patients with uncomplicated appendicitis, particularly those without appendicolith, perforation, or abscess. This approach can reduce surgical risks, recovery time, and healthcare costs for appropriate candidates 1.

Key Findings

• The APPAC trial demonstrated a success rate of 73% for antibiotic therapy in treating uncomplicated appendicitis.
• The trial showed that 27% of patients eventually required appendectomy within one year.
• The antibiotic regimen used in the trial was effective in reducing the need for surgery.
• The presence of an appendicolith is an independent prognostic risk factor for treatment failure in non-operative management of uncomplicated appendicitis.

Implications

• The APPAC trial provides evidence for the use of antibiotics as a safe first-line treatment option for selected patients with uncomplicated appendicitis.
• This approach can reduce surgical risks, recovery time, and healthcare costs for appropriate candidates.
• The trial's findings support the feasibility of non-operative management with antibiotics as an alternative to surgery for uncomplicated appendicitis. The 5-year follow-up results of the APPAC trial reported that, among patients who were initially treated with antibiotics, the likelihood of late recurrence was 39.1% 1.

Recommendations

• Antibiotic therapy should be considered as a first-line treatment option for selected patients with uncomplicated appendicitis, particularly those without appendicolith, perforation, or abscess.
• Patients should be carefully selected and excluded if they have gangrenous AA, abscesses, or diffuse peritonitis.
• The antibiotic regimen used in the APPAC trial, which includes intravenous ertapenem and oral levofloxacin and metronidazole, can be considered as a treatment option.

From the Research

Landmark Trial for Conservative Management of Uncomplicated Appendicitis

• The landmark trial that justifies conservative management for uncomplicated appendicitis is not explicitly stated in the provided studies, but several studies support the use of conservative management with antibiotics as an alternative to immediate appendectomy 2, 3, 4, 5, 6.

Key Findings

• A study published in 2021 found that treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups 4.
• Another study published in 2011 found that amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis, with a higher rate of postintervention peritonitis in the antibiotic group 5.
• A study published in 2017 found that conservative treatment in uncomplicated acute appendicitis had a success rate of 87%, with shorter hospital stays compared to children who eventually needed surgery 6.

Conservative Management

• Conservative management with antibiotics is a reasonable alternative to appendectomy for uncomplicated acute appendicitis, with a high success rate and low risk of complications 2, 3, 4, 5, 6.
• The choice of antibiotic regimen and duration of treatment may vary depending on the patient's condition and medical history 4.
• Patients who fail conservative treatment can be successfully operated on without significant morbidity 6.