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Antibiotic Treatment and Appendectomy for Uncomplicated Acute Appendicitis in Adults and Children

A Systematic Review and Meta-analysis

Podda, Mauro MD*; Gerardi, Chiara Pharm D; Cillara, Nicola MD; Fearnhead, Nicola MD, FRCS§; Gomes, Carlos Augusto MD, PhD; Birindelli, Arianna MD||; Mulliri, Andrea MD**; Davies, Richard Justin M Chir, FRCS§; Di Saverio, Salomone MD, FRCS§

doi: 10.1097/SLA.0000000000003225
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Objective: The aim of this meta-analysis was to summarize the current available evidence on nonoperative management (NOM) with antibiotics for uncomplicated appendicitis, both in adults and children.

Summary Background Data: Although earlier meta-analyses demonstrated that NOM with antibiotics may be an acceptable treatment strategy for patients with uncomplicated appendicitis, evidence is limited by conflicting results.

Methods: Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases for randomized and nonrandomized studies comparing antibiotic therapy (AT) and surgical therapy-appendectomy (ST) for uncomplicated appendicitis. Literature search was completed in August 2018.

Results: Twenty studies comparing AT and ST qualified for inclusion in the quantitative synthesis. In total, 3618 patients were allocated to AT (n = 1743) or ST (n = 1875). Higher complication-free treatment success rate (82.3% vs 67.2%; P < 0.00001) and treatment efficacy based on 1-year follow-up rate (93.1% vs 72.6%; P < 0.00001) were reported for ST. Index admission antibiotic treatment failure and rate of recurrence at 1-year follow-up were reported in 8.5% and 19.2% of patients treated with antibiotics, respectively. Rates of complicated appendicitis with peritonitis identified at the time of surgical operation (AT: 21.7% vs ST: 12.8%; P = 0.07) and surgical complications (AT: 12.8% vs ST: 13.6%; P = 0.66) were equivalent.

Conclusions: Antibiotic therapy could represent a feasible treatment option for image-proven uncomplicated appendicitis, although complication-free treatment success rates are higher with ST. There is also evidence that NOM for uncomplicated appendicitis does not statistically increase the perforation rate in adult and pediatric patients receiving antibiotic treatment. NOM with antibiotics may fail during the primary hospitalization in about 8% of cases, and an additional 20% of patients might need a second hospitalization for recurrent appendicitis.

*Department of General, Emergency and Robotic Surgery, San Francesco Hospital, Nuoro, Italy

Centro di Politiche Regolatorie del Farmaco, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, Milano, Italy

Department of Surgery, Santissima Trinità Hospital, Cagliari, Italy

§Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

Department of Surgery, Hospital Universitario Terezinha de Jesus, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil

||Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, AUSL Bologna Local Health District Bologna, Bologna, Italy

**Department of Digestive Surgery, University Hospital of Caen, Caen cedex, France.

Reprints: Dr. Mauro Podda, MD, Department of Surgery: General, Emergency and Robotic Surgical Unit, San Francesco Hospital, ASSL Nuoro, ATS Sardegna, Via Mannironi, 1, 08100 Nuoro, Italy. E-mail: mauropodda@ymail.com.

Contributions of authors: M.P.: Study conception and design, literature search, acquisition, interpretation and analysis of data; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. C.G.: Study conception and design, literature search, acquisition, interpretation and analysis of data; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. N.C.: Interpretation and analysis of data; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. N.F.: Interpretation and analysis of data; critically revising the article for important intellectual content; and final approval of the version to be published. C.A.G.: Interpretation and analysis of data; critically revising the article for important intellectual content; and final approval of the version to be published. A.B.: Interpretation and analysis of data; critically revising the article for important intellectual content; and final approval of the version to be published. A.M.: Interpretation and analysis of data; critically revising the article for important intellectual content; and final approval of the version to be published. R.J.D.: Interpretation and analysis of data; drafting and critically revising the article for important intellectual content; editing and revising the English for the final version to be published; and final approval of the version to be published. S.D.S.: Study conception and design, literature search, acquisition, interpretation and analysis of data; drafting and critically revising the article for important intellectual content; Editing and revising the English for the final version to be published; and final approval of the version to be published.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval: No ethical approval was required for this article.

The authors report no conflicts of interest.

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