From the Guidelines
Antibiotics are a crucial component in the treatment of appendicitis, and their use is recommended to decrease wound infection and postoperative intra-abdominal abscess. The most recent and highest quality study, published in 2020 in the World Journal of Emergency Surgery 1, supports the use of broad-spectrum antibiotics given preoperatively to reduce the risk of surgical site infections and intra-abdominal abscesses.
Key Points:
- A single dose of broad-spectrum antibiotics given preoperatively, from 0 to 60 minutes before the surgical skin incision, is effective in decreasing wound infection and postoperative intra-abdominal abscess.
- The recommendation is to use a single preoperative dose of broad-spectrum antibiotics in patients with acute appendicitis undergoing appendectomy.
- Postoperative antibiotics are not recommended for patients with uncomplicated appendicitis. Some studies suggest that antibiotics alone may be sufficient for uncomplicated appendicitis, with regimens such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole for 3-7 days 2. However, the choice between surgical and non-surgical management depends on the severity of the condition, patient factors, and clinical judgment. It is essential to note that while surgery remains the gold standard for many cases, particularly complicated ones, antibiotic therapy has shown effectiveness in selected uncomplicated cases, potentially avoiding surgical risks. Prompt treatment is essential regardless of the approach chosen, as delayed intervention increases the risk of complications. The use of antibiotics in appendicitis is supported by high-quality evidence, with a strong recommendation for their use in patients undergoing appendectomy 1.
From the FDA Drug Label
Piperacillin and Tazobactam for Injection is indicated in adults and pediatric patients (2 months of age and older) for the treatment of appendicitis (complicated by rupture or abscess) and peritonitis caused by beta-lactamase producing isolates of Escherichia coli or the following members of the Bacteroides fragilis group: B. fragilis, B. ovatus, B. thetaiotaomicron, or B. vulgatus.
Antibiotics are useful in appendicitis, specifically for the treatment of complicated appendicitis (with rupture or abscess) caused by certain bacteria, as indicated in the drug label for piperacillin-tazobactam 3, 4.
- The drug label specifies that piperacillin-tazobactam is indicated for the treatment of appendicitis complicated by rupture or abscess.
- It is essential to note that the use of antibiotics should be guided by culture and susceptibility information, and local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy 3.
From the Research
Effectiveness of Antibiotics in Appendicitis
- Antibiotics can be an effective treatment for uncomplicated acute appendicitis, with a success rate of 62.6% to 78% in some studies 5, 6.
- The use of antibiotics alone for treatment of uncomplicated acute appendicitis has been shown to have fewer immediate complications than surgery, but more subsequent failures 5, 7.
- A meta-analysis of randomized controlled trials found that antibiotic therapy was associated with a 39% risk reduction in overall complication rates compared to appendectomy 8.
Comparison with Appendectomy
- Appendectomy remains the first-line treatment for uncomplicated acute appendicitis, with a higher success rate (96.3%) compared to antibiotic therapy (62.6%) 6.
- However, antibiotic therapy may be a reasonable alternative for selected patients, as the incidence of complications does not differ significantly between the two treatments 6.
- Some studies have found that primary antibiotic treatment had fewer complications compared to primary surgery 9.
Considerations and Risks
- The risk of recurrence is higher with antibiotic therapy, with 14.2% to 37.4% of patients experiencing recurrent appendicitis 7, 6.
- The risk of complicated appendicitis is not increased in patients who undergo appendectomy after "failed" antibiotic treatment 8.
- Antibiotic therapy may be a suitable option for patients who are informed of the risks and benefits, and who prefer to avoid surgery 5.