Antibiotics: An alternative to appendectomy for paediatric uncomplicated appendicitis?

Nonoperative management using antibiotic therapy may be a suitable option for children with uncomplicated appendicitis, according to a study from the US.

This prospective, multicentre, nonrandomized study included 1,068 children aged 7–17 years with uncomplicated appendicitis (median age 12.4 years, 38 percent female). They were treated, according to patients/family choice, with a nonoperative regimen (antibiotics alone*; n=370) or laparoscopic appendectomy** conducted ≤12 hours of admission (n=698). Patients in the nonoperative group could cross over to the surgical group if there was clinical deterioration or no improvement within 24 hours of intravenous (IV) antibiotics.

Follow-up was completed by 77 and 75 percent of the nonoperative and appendectomy groups, respectively.

After adjustment, nonoperative therapy was deemed successful – defined as receiving the nonoperative regimen and not requiring appendectomy by 1 year – in 67.1 percent of patients (p=0.86). [JAMA 2020;324:581-593]

At 1 year, the number of disability days, where children were unable to participate in all their normal activities due to appendicitis-related care, was significantly lower in the nonoperative vs appendectomy group (adjusted mean 6.6 vs 10.9 days; mean difference, -4.3 days; p<0.001).

The reduction in disability days with the nonoperative regimen was also evident at 30 days (adjusted mean 3.3 vs 6.5 days; p<0.001), and among caregivers at 30 days (adjusted mean 2.4 vs 3.1 days; p=0.02) and 1 year (adjusted mean 3.3 vs 4.1 days; p=0.03).

During initial hospitalization, 85.4 percent of patients in the nonoperative group did not covert to appendectomy (p<0.001). Nonoperative management failed in 53 patients; in 16 cases, caregivers opted for surgery. Among the remaining patients, failure was due to clinical worsening in 16 patients.

Complicated appendicitis rates did not differ between the nonoperative and appendectomy groups (3.3 percent vs 3.6 percent; p=0.82). At 30 days, health care satisfaction scores also did not differ between the two groups (mean difference, -0.73; p=0.40), though satisfaction with decision scores was lower in the nonoperative group at 30 days (mean difference, -0.97; p<0.001) and 1 year (mean difference, -0.79; p=0.006).

Health-related quality of life scores at 30 days were better in the nonoperative vs appendectomy group (mean difference, 2.73; p=0.002 [patients] and 3.2; p<0.001 [caregivers]), though there was no significant between-group difference at 1 year.

“[Another benefit of the nonoperative regimen is] the possible avoidance of unnecessary negative appendectomies that occurred in 7.5 percent of patients in the surgical group,” the researchers said.

However, due to the definition of the minimal clinically important difference in this study, the overall result was deemed negative, said Dr Edward Livingston, JAMA deputy editor, in an editorial. [JAMA 2020;324:594]

The success threshold was set at 70 percent (surgeon’s preference) as opposed to 50 percent (multidisciplinary team’s preference). As such, 67.1 percent was below the acceptable success rate, the researchers noted.

Additionally, if negative appendectomy was considered a surgical failure, the 25.4 percent difference in failure rate between groups was lower than the stipulated 30 percent failure rate for nonoperative treatment, they added.

“[T]he study failed from the surgeon’s perspective, but patients would have considered this outcome a success,” Livingston pointed out. “Are antibiotics as good as surgery for paediatric appendicitis? The answer depends on who is asking the question,” he said.