Antibiotics Instead of Surgery Safe for Some, Experts Say; Others Say More Research Needed
By Kathleen Doheny
WebMD Health News
Reviewed by Laura J. Martin, MD
Appendicitis is an inflammation of the appendix. This tiny pouch attaches to the beginning of the large intestine.
''We conclude that antibiotic therapy is a safe initial therapy for patients with uncomplicated acute appendicitis," says study researcher Dileep N. Lobo, DM, professor of gastrointestinal surgery at the University of Nottingham in the U.K. Patients who have complications, such as perforation, still need surgical removal of the appendix, Lobo stresses.
However, he says, only about 20% of patients overall have complicated appendicitis when they seek medical help. "Our study suggests that the remaining 80% with uncomplicated appendicitis may be managed, at least initially, with antibiotics, and if their condition improves, they may not need an appendectomy."
In his analysis, antibiotics alone were effective for 63% of patients with uncomplicated appendicitis.
In an accompanying editorial, Olaf Bakker, MD, a surgical resident at the University Medical Centre Utrecht in the Netherlands, argues that more research is needed.
Antibiotics for Appendicitis: Details
Since 1889, doctors have believed that surgical removal of the appendix is best, Lobo writes.
They assumed that the appendix would burst. More recently, some experts have challenged this idea.
Doctors are likely to use CT scans to evaluate whether the appendicitis is likely to progress.
Some recent studies have found fewer problems with antibiotic treatment than surgery when the condition is not complicated.
So Lobo's team evaluated four published studies comparing the approaches. The studies included 900 patients. Of those, 470 got antibiotics and 430 got surgery. Antibiotics were given intravenously and then by mouth.
- Antibiotics were linked with a 63% success rate at one year. Other patients had to have surgery.
- Compared to surgery, antibiotic treatment had a 39% reduced risk of complications. This was after excluding those who were started on drugs but later needed surgery.
- A fifth of those treated with antibiotics had a return of symptoms and went back to the hospital. Of these, 19% had complicated appendicitis.
- The length of hospital stay was not different between the antibiotics and surgery groups.
Antibiotics for Appendicitis: Second Opinion
The idea does make sense, says Bakker, the editorial writer. He also participated in the writing of Dutch national treatment guidelines for acute appendicitis, he tells WebMD in an email interview.
However, he writes, "the use of antibiotics as first-line treatment for appendicitis has major disadvantages." One is the delay in surgery, if the condition progresses. That has been linked with a high complication rate, he says.
While doctors use imaging tests to evaluate the condition, "it's not 100%," Bakker tells WebMD
"The [study] tackles an interesting issue, but also shows that we need more evidence," he says.
The Approach in the U.S.
The concept of antibiotic treatment is catching on much more slowly in the U.S. than overseas, says Paresh C. Shah, MD, director of laparoscopic surgery and a gastrointestinal surgeon at Lenox Hill Hospital in New York. He reviewed the findings for WebMD.
"The concept of treating it with antibiotics has been around in Europe for a long time," he tells WebMD.
Many U.S. doctors do support the idea of initial treatment with antibiotics and delayed surgical intervention if the condition does not look complicated, he says.
In years past, he says, if someone came to the hospital with appendicitis, surgery would be performed as soon as possible, even in the middle of the night.
Now, he says, a typical approach if the doctor believes it is uncomplicated is to start antibiotics but also schedule surgery for the next day or so.
One shortcoming of the analysis, he says, is lack of data on costs.
While surgery would be more costly, Shah notes that the difference may not be that great. The antibiotic group was in the hospital while on IV drugs. The researchers found no overall differences in length of hospital stays between the groups.
The study and editorial are published online in BMJ.
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SOURCES: Varadhan, K. BMJ, April 5, 2012.Bakker, O. BMJ, April 5, 2012. Dileep Lobo, DM, professor of gastrointestinal surgery, University of Nottingham, Nottingham, U.K. Olaf Bakker, MD, surgical resident, University Medical Centre Utrecht, Utrecht, Netherlands. Paresh C. Shah, MD, director of laparoscopic surgery, Lenox Hill Hospital, New York.
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