Surgery to remove the appendix, called appendectomy, is the go-to treatment for patients with appendicitis and is one of the most common surgical procedures in the U.S. However, antibiotic drugs could take the place of surgery for the many patients who have mild cases of appendicitis, according to new research.
Researchers in Finland studied more than 500 adults who had uncomplicated appendicitis, meaning their appendixes had not ruptured and they had no signs of infection or other problems in their abdomens. Half of the patients received an appendectomy, which is the standard of care, while the other half got an IV of antibiotics for three days followed by antibiotic pills for a week.
The researchers found that 73% of the patients who took antibiotics recovered from appendicitis and did not need surgery for at least a year afterward. The rest of the patients — who went on to have another case of appendicitis and need an appendectomy — did not have a higher rate of complications than the patients who initially received surgery.
“This is quite a radical change in the line of thinking, because appendectomy has served patients well for over 100 years,” said Dr. Paulina Salminen, a surgeon at the Turku University Hospital in Finland and lead author of the study, which was published on Tuesday in The Journal of the American Medical Association. An editorial accompanying the study added, “the time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis.”
The findings suggest that for patients with uncomplicated cases, who make up about 80% of the patients diagnosed with appendicitis, surgery may not be necessary, Salminen said. However, if the appendix has ruptured, emergency surgery must be done because patients can develop deadly infections in the abdomen and antibiotics alone are not strong enough to treat them, she added.
Several previous studies have compared appendectomy with antibiotics, but most of them have relied on clinical examination to diagnose uncomplicated appendicitis. The current study relied on CT scans, which are a more accurate way to diagnose the disease and to make sure only patients with simple cases are studied, Salminen said.
Still, in both the current study and a 2011 study that also used CT scans, more than a quarter of patients who were treated with antibiotics for their well-diagnosed cases of simple appendicitis had a recurrence of appendicitis and ended up needing surgery. In contrast, the failure rate was less than 1% in the group that initially got an appendectomy in the current study. (One patient died of heart disease in the week after surgery.)
The high failure rate of antibiotic therapy suggests that it is not ready for the clinic, said Dr. Curtis Wray, an associate professor of surgery at the University of Texas Health Science Center at Houston. “I think we need to determine who are really the candidates for this type of nonoperative therapy,” Wray said.
Part of the reason for the 27% failure rate could be that the antibiotics did not clear up the obstruction in the appendix that was the root cause of the inflammation. More analyses need to be done to understand how this group differed from the other 73% — maybe they had more advanced appendicitis — and thus to be able to predict who might not make a full recovery with antibiotics alone, Wray said.
If antibiotic therapy does become a viable alternative to appendectomy, it would probably lead to a big cost savings, Wray said. There are about 300,000 appendectomies performed every year in the U.S. About 200,000 of them are uncomplicated cases, many of which could be good candidates for antibiotics.
However, as Wray pointed out, it may take a little while for this nonsurgical option to be accepted by patients, because appendectomy is considered the gold standard. In addition, laparoscopic appendectomy is minimally invasive and patients usually go home the same day, he added.
Nevertheless, Salminen said that surgery can cause several days of pain and missed work, whereas patients would probably not experience pain following antibiotic therapy and would have a faster recovery.
Because the study only looked at people between 18 and 60, it is not clear how effective antibiotic therapy would be in children, the group that accounts for most cases of appendicitis. Other researchers are planning to do a similar study in children, Salminen said.
Salminen and her colleagues also did not include pregnant women in the study. “You can’t really do a CT scan on pregnant women, so you can’t really have the precise diagnosis, so to be on the safe side those patients would probably have to undergo appendectomy,” she said.
The study gave patients in the antibiotic group an IV of ertapenem once a day for three days and then prescribed a week of oral antibiotics, levofloxacin and metronidazole.
“Every time you use antibiotics, you have to think about the risk of developing antibiotic resistance, (especially) because the antibiotics used here are very broad spectrum,” Salminen said. She added that future studies should look at whether lower doses of antibiotics, and the use of more specific antibiotics that may be less likely to lead to resistance, could also be effective in treating appendicitis.