Most cases of uncomplicated acute appendicitis can be treated using antibiotics and do not require surgery, according to a large study from Finland that has turned on its head the standard treatment for the very common, painful and potentially life-threatening abdominal infection.
Using antibiotics alone treated three in five patients with uncomplicated, with only 39.1% of the patients initially treated with antibiotics alone needing surgery over the next five years, found the five-year observational follow-up of 257 patients ages 18 to 60 years in Finland.
“This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis,” the say authors in the study published in JAMA, which is the Journal of American Medical Association.
The appendix is a finger-shaped pouch in the colon located in the lower right abdomen. Once considered a useless, vestigial organ that was expendable, the appendix has lately been identified as a reservoir for beneficial “good” gut bacteria, which helps the digestive system recover after bouts of diarrhoeal and other gastrointestinal illnesses.
For more than a century, surgery has been the standard treatment for appendicitis, which is an inflammation of appendix because of acute infection and that causes symptoms of sudden, severe pain in the lower abdomen, nausea, vomiting and abdominal bloating. Uncomplicated appendicitis is infection without complications such as perforation, abscess, or suspicion of a tumour.
Antibiotic treatment led to fewer complications and faster recoveries, with the antibiotic group taking an average of 11 days of sick leave to recover, compared to 22 days taken by those who underwent surgery. Antibiotics also lowered complication rate to 6.5%, compared a rate of 24% post surgery, mostly as a result of infections.
Though the study did not compare costs, patients who do not undergo an operation spend less on treatment, including treating surgical complications.
On average, the surgery patients stayed in the hospital for three days, while those treated using antibiotics were given three days of intravenous drugs in hospital, followed by one week of oral antibiotics prescription after discharge. The antibiotics used were intravenous Ertapenem for three days followed by seven days of oral Levofloxacin and Metronidazole, all of which are broad-spectrum antibiotics that act against a wide range of disease causing bacteria.
An important finding was that none of the patients in the antibiotics group who eventually needed an operation had complications related to delaying surgery. “Although patients may be concerned about the ultimate need for surgery from the health outcome perspective, non-surgical treatment in uncomplicated appendicitis before proceeding for surgery is a reasonable option,” said an accompanying editorial in JAMA.
The study’s finding is not entirely surprising and is a long-term follow-up Appendicitis Acuta (APPAC) trial in 2015, which compared the outcomes for open appendectomy (appendix removal) with antibiotic therapy for acute uncomplicated appendicitis and declared antibiotics were a reasonable alternative to surgery. Of the 257 patients in the antibiotic group, 186 (73%) initially treated with antibiotics did not require surgery after one year, but concerns were raised on whether the antibiotics just improved the situation temporarily and if initial drug treatments left patients worse off later if they eventually did need surgery.
Despite the evidence on the effectiveness of antibiotics, experts groups recommended that the APPAC results could not be used for clinical decision-making until the long-term outcomes were known for the patients on antibiotic treatment, which was provided by the few study.
These findings have great implications in places, such as many parts of rural India, where surgeons are not available 24×4 for emergency surgeries. Further research now needs to identify the best treatment for appendicitis compared to minimally invasive laparoscopic surgery, which is replacing conventional open surgery in most parts of the world, including in India.