Here are a few thoughts about the latest chapter in the never-ending debate about antibiotics vs. surgery for the treatment of uncomplicated appendicitis.
You will recall the randomized controlled trial from Finland published in 2015 that found a 27% rate of failure of antibiotics within the first year.
Now that the patients have now been followed for five years, 100 (39%) of the 246 patients treated with antibiotics have experienced persistent or recurrent symptoms requiring appendectomy. Depending on your point of view, this shows that antibiotics are successful for the treatment of simple appendicitis or not.
All of the original 273 patients randomized to appendectomy and the 100 who had subsequent appendectomy after antibiotic failure were cured of appendicitis.
The more recent paper, published in JAMA, states complications — surgical site infections, ventral hernias, abdominal pain, and symptoms of obstruction — occurred in 24.4% of those who had surgery compared to only 16 (6%) of the 246 patients initially treated with antibiotics.
Nearly all the patients who had surgery underwent open appendectomies, not the standard of care in the United States where laparoscopic appendectomies are performed more than 90% of the time. Complications after laparoscopic appendectomy are much less frequent than the 24% reported in the Finnish study. In one paper, which included patients with complicated appendicitis, the complication rate after laparoscopic appendectomy in 283 patients was only 10%.
The reported complication rate after antibiotic treatment conveniently ignores the 100 patients who eventually had appendectomies. Obviously, all of them must have had abdominal pain or they would not have needed surgery. If abdominal pain had been properly counted as a complication in the antibiotic group, the complication rate would be 100/246 or 41%.
Other complications of antibiotic therapy such as diarrhea, drug reactions, and revisits to physicians’ offices or emergency departments for abdominal pain necessitating laboratory studies, CT scans, and readmissions were not addressed in the Finnish study.
The antibiotics used in the Finnish randomized trial were intravenous ertapenem, which was administered during a hospital stay of three days, followed by seven days of oral levofloxacin and metronidazole. Ertapenem is not a first line drug in the U.S. and the combination of the two oral drugs may not be tolerated by some patients. It is not clear whether using different antibiotics would yield the same results.
We now know that 39% of patients treated with antibiotics for simple appendicitis will require an appendectomy for recurrent abdominal pain within five years of their original presentation. This begs the question, what will the recurrence rate be at 10 or 20 years?
A multicenter randomized trial of antibiotics vs. surgery for simple appendicitis involving 21 hospitals in the U.S. has enrolled over 800 patients. We eagerly await the results.
Meanwhile, before deciding to treat uncomplicated appendicitis with antibiotics, all of the above should be mentioned as part of the shared decision-making process.
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