Antibiotic therapy is inferior to surgery for children with uncomplicated appendicitis

1. Treatment failure was greater in the antibiotic group compared to appendicectomy group.

2. Significantly more patients in the antibiotic group reported mild-to-moderate adverse events.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Recent studies have supported non-operative management of uncomplicated appendicitis in children instead of surgery. However, whether this approach is truly comparable to appendicectomy remains uncertain. This randomized controlled trial aimed to compare the failure rates of antibiotic treatment versus appendicectomy for non-perforated appendicitis. The primary outcome of this study was treatment failure within one year, defined as the need for appendicectomy or additional procedures. A key secondary outcome was the occurrence of adverse events. According to study results, treatment failure was significantly greater in the antibiotic group compared to appendicectomy, and those receiving antibiotics had a greater risk of mild-to-moderate adverse events. Although this study was well done, it was limited by its non-inferiority design, which allowed for a relatively high failure margin and may not fully capture long-term outcomes.

Click to read the study in The Lancet

Relevant Reading: A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

In-depth [randomized controlled trial]: Between Jan 20, 2016, and Dec 3, 2021, 9988 patients were assessed for eligibility across 11 children’s hospitals in Canada, USA, Finland, Sweden, and Singapore. Included were patients aged 5–16 years with suspected non-perforated appendicitis diagnosed clinically with or without radiological confirmation. Altogether, 936 patients (459 to appendicectomy and 447 to antibiotics) were included in the final analysis. The primary outcome of treatment failure was greater in the antibiotic group compared to the appendicectomy group (34% vs. 7%, 90% confidence interval [CI] 22.4-30.9). The secondary outcome of mild-to-moderate adverse events was also higher in the antibiotic group (relative risk [RR] 4.3, 95% CI 2.1-8.7, p<0.0001). Overall, findings from this study suggest that antibiotic management of non-perforated appendicitis in children is inferior to appendicectomy.

Image: PD

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