A Non-Surgical Option for Appendicitis

Antibiotic treatment may work for some acute appendicitis patients

(RxWiki News) For well over 100 years, most appendicitis patients were treated with surgery. Now there may be a second option for some patients.

A new study found that antibiotic treatment for acute uncomplicated appendicitis worked in most cases. Using drugs rather than surgery could help patients avoid some complications.

The authors of this study did not say antibiotic treatment should become the standard of care. They did suggest further research on the issue, however.

F. Paul "Tripp" Buckley, MD, surgical director of the Heartburn and Acid Reflux Center at Scott & White Healthcare in Round Rock, TX, however, said he believes that the trial may not be relevant to patients in the US.

"In this Finnish trial they kept their surgical patients in the hospital for an average of three days and the majority were performed using an open technique," Dr. Buckley told dailyRx News. "Here in the US most of these patients would have undergone a laparoscopic procedure which is often performed as an outpatient or certainly less than a 24-hour stay. This is significant from the standpoint of cost and time away from work."

Dr. Buckley, who was not involved with the current study, added, "This trial is useful in that it gives us treatment options for patients, particularly those who may not be fit for surgery."

Lead study author Paulina Salminen, MD, PhD, of Turku University Hospital in Finland, and team wrote that "the majority (73 percent) of patients with uncomplicated acute appendicitis were successfully treated with antibiotics."

The appendix is a small tube connected to the large intestine. Appendicitis occurs when the appendix becomes inflamed. If untreated, appendicitis can cause a perforation of the bowel and lead to death.

Surgical removal is the gold standard for treating appendicitis. The procedure is known as an appendectomy. Surgery has risks like infection, bleeding and anesthetic complications, however. These might be avoided with other treatments.

Appendicitis is known to cause infection in the abdomen. Dr. Salminen and team theorized that antibiotics could prevent the infection, giving the body time to heal on its own.

Dr. Salminen and colleagues set a target of a 24 percent failure rate as successful. In other words, if 76 of 100 patients got well without surgery, antibiotic treatment could be considered equally successful when compared to surgery.

These researchers randomly assigned 530 patients who had been diagnosed with acute uncomplicated appendicitis to one of two groups.

The first group received the standard surgery. The second group received three different antibiotics over 10 days.

These researchers used intravenous ertapenem sodium (brand name Invanz) as the initial antibiotic treatment. This was followed by oral levofloxacin (brand name Levaquin) and metronidazole (brand name Flagyl).

In the surgery group, 273 patients had an appendectomy. The surgery was successful in all but one case, for a 99.6 percent success rate.

In the antibiotic group, 70 patients needed an appendectomy within one year of the antibiotic treatment. The antibiotic failure rate was 27.3 percent, higher than the 24 percent failure rate set by Dr. Salminen and colleagues.

Although the antibiotic treatment was not as successful as surgery, 187 patients did recover without any major complications when treated only with antibiotics.

Patients who received the antibiotic regimes stayed in the hospital longer than those who had surgery. However, Dr. Salminen and team noted that the longer stay was part of the research protocol. They said it was unlikely that length of stay would be much different in real life.

In an editorial about this study, Edward Livingston, MD, deputy editor of JAMA, Chicago, and Corrine Vons, MD, PhD, of the Jean­ Verdier Hospital in Bondy, France, wrote, “These findings suggest that for ... uncomplicated appendicitis, an initial trial of antibiotics is reasonable followed by elective appendectomy for patients who do not improve with antibiotics or present with recurrent appendicitis. The time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis.”

The study and editorial were published June 16 in JAMA.

A grant from the EVO Foundation to Turku University Hospital funded this research. Dr. Salminen received fees from Merck — which makes Invanz — and Roche, which also makes antibiotics.

Review Date: 
June 15, 2015