Therapeutic Targets
- Avoidance of complications
- Healing of appendicitis
Therapy recommendations
- Adults
- In uncomplicated acute appendicitis (i.e., no evidence of perforation of the appendix (“appendicitis rupture”) – see Medical Device Diagnostics for details – and/or peritonitis/peritonitis), antibiotic therapy (beta-lactams – amoxicillin + clavulanic acid or cefotaxime – possibly combined with imidazole) with observation and waiting is a possible reasonable strategy. Sixty-three percent of patients treated in this manner responded to therapy. The relative risk of complications was 31% lower with antibiotic therapy than with appendectomy (RR 0.69; 95% CI 0.54-0.89; p = 0.0049.
- Antibiotic therapy prevented three of four surgeries for uncomplicated appendicitis in adult patients; one in four patients still required appendectomy within 1 year.A 5-year follow-up showed that among patients with uncomplicated acute appendicitis initially treated with antibiotics, the probability of late recurrence within 5 years was 39.1%. This finding supports the feasibility of antibiotic therapy as an alternative to surgery for uncomplicated acute appendicitis.
- According to a retrospective study (data 58,329 privately insured patients), a significantly higher incidence of follow-up occurred after antibiotic treatment instead of surgery for uncomplicated appendicitis:
- In the first 30 days, 4.6% required hospitalization again versus 2.5% of patients who had surgery.
- A total of 2.6% of nonoperated patients were hospitalized for appendicitis-associated complications within 30 days versus 1.2% of operated patients.
Additional results:
- In 8 of the unoperated patients, appendiceal carcinoma was missed as a long-term complication (≥ 30 days) (absolute rate: 0.3%).
- Only 3.9% of patients underwent appendectomy after all during a follow-up period of 3.2 years.
- Antibiotic treatment of appendicitis with abscess formation in older adults: To avoid potential complications from surgery, appendicitis with abscess formation is initially treated conservatively with antibiotics and, if necessary, drainage.After the acute inflammation has resolved, an interval appendectomy is performed if necessary. The PeriAPPAC study (for “The Treatment of Periappendicular Abscess After the Acute Phase”), when 122 patients with periappendicular abscess were randomized into two groups (one was to have interval appendectomy and the other was to forgo it), the study was terminated after an interim evaluation of the group with interval appendectomy. Low-grade mucinous neoplasia was detected in the area of the former abscess in 12 of 60 patients, i.e., in one in five patients, serrated adenoma in three other patients, and two patients had adenocarcinoma and one each carcinoid tumor, mucinous cystadenoma, or pseudomyxoma peritonei. The age of patients with tumors was reported to be over 40 years.Previously, neoplasms of the appendix were thought to occur with a frequency of 0.7% to 1.7%.
- Children
- In uncomplicated acute appendicitis, antibiotic therapy with observation and waiting is probably also a possible useful strategy in children.In a metaanaylsis of five clinical trials, children with appendicitis confirmed by computed tomography or sonography (ultrasonography) were treated as follows: of 404 patients
- 168 (= 42%) were initially treated with antibiotics; of these, antibiotics occurred in
- 152 patients (90.5%) resulted in a cure
- 16 patients (9.5%); of these, there were or had been
- Eleven underwent surgery within 48 hours
- Five patients relapsed (recurrence of disease) within one month of antibiotic therapy and underwent appendectomy (surgical removal of the appendix vermiformis).
- Appendicitis was confirmed histologically in the 16 patients, and perforation was present in three of the 16 children.The 236 children who underwent immediate surgery also had histologically confirmed appendicitis.
- 168 (= 42%) were initially treated with antibiotics; of these, antibiotics occurred in
- CONCLUSION: Antibiotic treatment was 90% successful; however, there remains an 8.92-fold risk of antibiotic therapy failure (risk ratio 8.92; 95 percent confidence interval 2.67-29.79).
- In uncomplicated acute appendicitis, antibiotic therapy with observation and waiting is probably also a possible useful strategy in children.In a metaanaylsis of five clinical trials, children with appendicitis confirmed by computed tomography or sonography (ultrasonography) were treated as follows: of 404 patients
- Postoperative antibiotic prophylaxis after acute complicated appendicitis: 3-day antibiotic prophylaxis compared with 5-day antibiotic prophylaxis showed no statistically significant differences in:
- Rate of complications from infections (odds ratio [OR]: 0.93; 95% confidence interval between 0.32 and 2.32; p = 0.88).
- Rate of intra-abdominal abscesses (pus cavity within the abdominal cavity: OR: 0.89; 95% confidence interval between 0.34 and 2.35; p = 0.81)
- Perforation of the appendix (“rupture of the appendix”) is considered the only independent risk factor for complication due to infection (OR: 4.90; 95% confidence interval ranging from 1.41 to 17.06; p = 0.01) and intra-abdominal abscess (OR: 7.46; 95% confidence interval ranging from 1.65 to 33.66; p = 0.009), according to one study.
