Antibiotics can be first-line therapy for uncomplicated appendicitis cases

DURHAM, N.C. – With numerous recent studies demonstrating that antibiotics work as well as surgery for most uncomplicated appendicitis cases, the non-surgical approach can now be considered a routine option, according to a review article in JAMA.

The finding -- appearing Dec. 14 and led by Theodore Pappas, M.D., professor in the Department of Surgery at Duke University School of Medicine -- cites the consensus of evidence that antibiotics successfully treat up to 70% of appendicitis cases. Surgery, usually done laparoscopically, remains the definitive option for otherwise healthy patients with a severely inflamed appendix or other factors that increase the risk of rupture.

“Acute appendicitis is the most common abdominal surgical emergency in the world, striking about one in 1,000 adults,” Pappas said. “Until recently, the only treatment option was surgery, so having a non-surgical approach for many of these cases has significant impact for both patients and the health care system.”

Pappas said the criteria for determining the best treatment approach is nuanced, but not excessively difficult. Appendicitis cases -- marked by abdominal pain that often migrates to the lower right side, nausea and vomiting, and low-grade fever – are confirmed with ultrasound and/or CT scans.

If the scans depict no complications, most of these patients could receive antibiotics instead of undergoing an appendectomy. Antibiotics could also be a first-line therapy for patients who have severe symptoms, but who are older or have medical conditions that add risks to surgeries.

“We think it’s going to be 60% to 70% of patients who are good candidates for consideration of antibiotics,” Pappas said. “A lot of people note that patient preferences can be brought into the decision, so it is important to provide the literature and educate the public.”

Pappas added that antibiotics are not always a complete cure. In about 40% of cases, patients who recover from a bout of appendicitis after receiving antibiotics have another episode and eventually need their appendix surgically removed.

“It’s important to take into account every case and it’s unique context as we consider patient preferences,” Pappas said. “If someone presents with an appendicitis and they’re attending their brother’s wedding the next day, antibiotics may be a good option. If they have appendicitis and they are planning to head to rural Alaska next year, they might want to consider an appendectomy, given that the condition could recur.”

In addition to Pappas, study authors are Dimitrios Moris, a Duke surgical resident, and Erik K. Paulson, chair of the Department of Radiology at Duke.

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