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Antibiotics To Treat Appendicitis: a Safe Alternative

2015-06-17

A new Finnish study has given support to a formerly discredited method of treating appendicitis: antibiotics.  Surgical treatment for appendicitis has been the standard of care for over a hundred years, ever since the abdomen could be safely opened under anesthesia and long before antibiotics were even available.  By the time effective antibiotics were developed, surgery was ensconced as the only reasonable treatment option.

Now, a big study published in the Journal of the American Medical Association (JAMA) raises questions about that standard care.  530 patients were enrolled from 2009 to 2012 in Finland; all had uncomplicated appendicitis confirmed by CAT (computer assisted tomography) scans.  Patients with an appendicolith (a stony obstruction of the mouth of the appendix), perforated appendix, abscess, or other complications were judged inappropriate candidates for antibiotic therapy.  After randomization, 273 patients were assigned to immediate appendectomy and 257 were admitted to hospital for three days of intravenous ertapenem followed by seven days of oral metronidazole and levofloxacin.  Seventy of the patients assigned to antibiotics underwent appendectomy within 1 year and 186 did not require surgery.  Of the patients assigned to surgery, all but one underwent successful appendectomy; open surgery rather than laparoscopy was performed because the study would be more generalizable to locations where laparoscopy is not available.

Most of the patients who suffered complications from surgery had wound infections, which would also have been possible even if laparoscopic surgery had been done.  It has been noted that virtually all patients who have ruptured appendices already have a rupture by the time they present for treatment; almost no ruptures occur after the patient has arrived at the hospital.   Of the patients assigned to initial antibiotic treatment who subsequently underwent surgery, 58 had uncomplicated appendicitis, 7 had complicated acute appendicitis, and 5 did not have appendicitis but had appendectomy for suspected recurrent appendicitis.  There were no intra-abdominal abscesses and no other significant complications in the antibiotic-first group.

The surgeons who performed the study felt that the failure rate of  27% was acceptable, but in a New York Times (NYT) article about the study,  “Dr. Philip S. Barie, a surgeon at Weill Cornell Medical College, noted that antibiotics were not sufficient for more than a quarter of the patients in the new study and said the failure rate was unacceptable.”  Others feel that the failure rate is perfectly acceptable when the cost of surgery and the fact that no complications occurred is taken into account.

A repeat study is planned in America, with laparoscopic surgery; in addition, trials of shorter antibiotic courses are under discussion.  Many of the patients in the Finnish study were asymptomatic within a day or two and asked to be sent home early.   However, patients who have had one episode of appendicitis are at higher risk of a repeat episode, and there is some discussion about whether a patient who has been treated with antibiotics might go to the hospital every time he or she has a pain in the abdomen and require another CAT scan to rule out a recurrence, a potential additional expense.

There is an even more radical alternative: not treating patients with uncomplicated appendicitis at all and waiting to see if the condition would subside spontaneously.  The Finnish group is planning a trial to see if this is a potentially acceptable alternative.

The abstract for the JAMA study is here:  http://jama.jamanetwork.com/article.aspx?articleid=2320315  and the NYT article is linked here: http://www.nytimes.com/2015/06/17/health/study-supports-antibiotic-use-to-treat-appendicitis.html

 

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