Antibiotic treatment for acute appendicitis : uncertain potential benefits

Antibiotic treatment for acute appendicitis : uncertain potential benefits

SOURCE

Doleman B, Fonnes S, Lund JN, Boyd-Carson H, Javanmard-Emamghissi H, Moug S, Hollyman M, Tierney G, Tou S, Williams JP. (2024)

Appendectomy versus antibiotic treatment for acute appendicitis.

Cochrane Database of Syst Rev 4, CD015038.

CONTEXT

Appendicitis is one of the most common surgical emergencies, with an incidence ranging from 105 to 151 cases per 100,000 people per year in Europe. In 20% of cases, it presents as uncomplicated appendicitis, defined by transmural inflammation without necrosis, perforation, or abscess. During the COVID-19 pandemic, a greater number of uncomplicated appendicitis cases were managed with antibiotic therapy due to the closure of operating rooms.

CLINICAL QUESTION

What are the impacts of antibiotic treatment for uncomplicated acute appendicitis, compared to surgical management, on mortality, treatment success rate, the subsequent need for surgery, and adverse events?

BOTTOM LINE                                                                                                                                                                               There is little to no difference in mortality between antibiotic and surgical treatment for uncomplicated acute appendicitis; however, the evidence is very uncertain (low level of evidence). Antibiotic treatment may slightly reduce the treatment success rate, although this difference is not clinically significant (moderate level of evidence). After one year, more than two-thirds of patients initially treated with antibiotics avoided surgery, but the evidence remains very uncertain (low level of evidence).

Regarding adverse events, it is unclear whether there is a difference in the incidence of Clostridium difficile diarrhoea (low level of evidence). Antibiotics may lead to a clinically significant reduction in wound infections (moderate level of evidence). It is uncertain whether antibiotic treatment reduces the occurrence of intra-abdominal abscesses or fluid collections, or the length of hospital stay (low level of evidence).

CAVEATS                                                                                                                                                                                          The evidence is generally uncertain because participants in the studies were aware of the treatment they received. Future research should: 1) include high-risk surgical patients for whom antibiotics may offer greater benefit; 2) identify patients with a low risk of failure from non-surgical management; and 3) assess very early hospital discharge strategies to optimize the potential benefits of antibiotics.

AUTHORS

Y. Auffret

y.aunmail@gmail.com

Urgence SMUR, F-29200 Brest, France

D. Meyran

daniel.meyran@me.com

 Bataillon de Marins-Pompiers de Marseille, F-13233, Marseille, France