Hold the knife - are antibiotics a reasonable option for pediatric appendicitis?

EBM Focus - Volume 15, Issue 19

Reference: Ann Surg. 2020 Jun;271(6):1030-1035

Up to 8% of children presenting to emergency wards with acute abdominal pain will have appendicitis. Appendectomy is considered the standard treatment. There has been recent interest in initially managing selected patients who have acute appendicitis with antibiotics to delay or avoid surgery altogether. In November, an Italian group reported a meta-analysis of 14 studies involving over 1,200 children demonstrating that non-operative management (NOM) of acute appendicitis resulted in better short-term outcomes for patients with complicated appendicitis (that is, with abscess or phlegmon visible on imaging) as long as there was no perforation. In January, a group from Stockholm looked at five-year outcomes from children with non-perforated appendicitis—including patients with abscess or phlegmon as well as an isolated inflamed appendix—randomized to either appendectomy or antibiotics.

Fifty children aged 5-15 years with radiologic (primarily ultrasound) diagnosis of non-perforated appendicitis were randomized to either antibiotics or appendectomy. Antibiotic management consisted of at least 24 hours of IV meropenem and metronidazole followed by ten days of antibiotics with oral ciprofloxacin and metronidazole. All were followed for at least five years after randomization. Of the 24 children enrolled in the antibiotic arm, two required surgery within a month, one for a perforated appendix and the other for persistent abdominal pain that operatively revealed a non-inflamed appendix. At five years follow-up, another nine children in the antibiotic group had appendectomy for either recurrent pain or parental request. In other words, 11 of 24 children initially diagnosed with non-perforated appendicitis and treated with antibiotics eventually received an appendectomy, but only four of these children had appendicitis at the time of surgery. Of the patients assigned to the early appendectomy group, none had problems related to their surgery, and of the patients initially assigned to NOM who subsequently underwent appendectomy, none had bowel obstruction, “deep” abscess, or other serious consequences of delaying surgery.

This long-term follow-up of a small randomized controlled trial offers additional evidence that initial antibiotic management of non-perforated appendicitis is a reasonable option in children. This builds on the emerging paradigm that appendicitis without perforation is not universally progressive or recurrent. It is noteworthy that two of the patients who underwent appendectomy and one of the two who had initial NOM followed by appendectomy had perforation that was missed radiographically but diagnosed surgically. We can’t tell if this represents a missed radiologic diagnosis or progression between the study and subsequent operation. However, it suggests that the antibiotic-only strategy should be limited to patients able to have close follow-up in the short term. The meta-analysis and this study provide additional data to help our patients make informed choices about operative versus non-operative management for acute appendicitis.

For more information, see the topic Appendicitis in Children in DynaMed.

DynaMed EBM Focus Editorial Team

This EBM Focus was written by Dan Randall, MD, Deputy Editor for Internal Medicine at DynaMed. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School, and Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed.