Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. RETRACTED ARTICLE: Conservative Management of Acute Appendicitis Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues? Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis [Preventive use of single dose antibiotics in acute appendicitis. Results of a prospective randomized clinical study]. Perforated appendicitis: prospective outcome analysis for 150 children. Retraction Note to: Conservative Management of Acute Appendicitis The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Nonperforative appendicitis: a continuing surgical dilemma. Management of Complicated Appendicitis and Comparison of Outcome with Other Primary Sites of Intra-abdominal Infection: Results of a Trial Comparing Ertapenem and Piperacillin-Tazobactam [General or individually calculated preventive antibiotic administration. Summary of the Magdeburg appendicitis study]. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. Ultrasound-based decision making in the treatment of acute appendicitis in children. Non‐operative Management for Uncomplicated Appendicitis: An Option to Consider Management of peritonitis in perforated appendicitis in children.
In a prospect i ve controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated . Of 40 patients admitted with a duration of abdominal pain of less than 72 h , 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were r and omized to surgery . All patients treated conservatively were discharged within 2 days , except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis . Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery , when appendicitis was confirmed . The diagnostic accuracy within the operated group was 85 per cent . One patient had perforated appendicitis at operation .  Antibiotic treatment  in patients with  acute appendicitis was as effective as surgery . The patients had less pain and required less analgesia , but the recurrence rate was high BACKGROUND Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial . We studied the results of initial conservative treatment ( antibiotics and percutaneous drainage if necessary , with or without interval appendectomy ) compared with immediate surgery . METHODS We undertook an observational , retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon , treated in our hospital between January 1997 and March 2009 . Patients younger than 14 , with severe sepsis or with diffuse peritonitis were excluded . A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment . A control group was composed of the other patients , who all underwent  urgent appendectomy  , matched for age and later r and omized 1:1 . The infectious risk stratification was established with the National Nosocomial Infections Surveillance System ( NNIS ) index . Dependent variables were hospital stay and surgical site infection . Analysis was with SPSS , with p < 0.05 considered significant . RESULTS Interval appendectomy  was performed in 7 study group patients . Surgical site infection episodes were more frequent in the control group ( 6 vs. 0 , p < 0.001 ) . A greater percentage of high risk patients ( NNIS ≥ 2 ) was identified in the control group ( 80 vs. 28.7 % , p < 0.03 ) , mostly related with contaminated or dirty procedures in this group ( p < 0.001 ) . No significant difference between groups was found in hospital stay . CONCLUSION Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon Background The acute appendicitis is the most common abdominal emergency , and the primary treatment has been appendicectomy . Antibiotics are started preoperatively and continued postoperatively as needed . Methods This prospect i ve study was carried out at Sher-i-Kashmir Institute of Medical Sciences , Soura , Srinagar , Kashmir , India to determine the role of antibiotics as the only treatment in acute appendicitis and the analgesic consumption needed . Total of 80 patients were included in the study with a duration of abdominal pain less than 72 h. Out of 80 patients , 40 patients received antibiotics intravenously for 2 days followed by oral treatment for 7 days , while another 40 patients considered as controls were r and omized to surgery . Results Patients managed conservatively were discharged within 3 days except for two— patients who required surgery after 12 and 24 h , respectively , because of peritonitis due to perforated appendicitis . Four patients were readmitted within 1 year as a result of recurrent appendicitis and had to undergo surgery when appendicitis was confirmed . The diagnostic accuracy within the operated group was 90 % . Two patients had perforated appendicitis at operation . Conclusion Our conclusion is that antibiotic treatment in the patients with acute appendicitis is quite effective , and these patients may not need surgery . The patients managed conservatively with antibiotics alone experience less pain and require less analgesia but have high recurrent rate An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis . The objective of this study was to compare the costs of antibiotics alone  versus  appendicectomy  in treating uncomplicated acute appendicitis within the r and omized controlled APPAC ( APPendicitis ACuta ) trial Introduction : The management approach for acute appendicitis has been challenged in recent years , with numerous r and omized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment , with lower complication rates . Methods : A national survey of all consultant general surgeons evaluating their practice s was performed . Reasons for changed practice s , choice of antibiotics and follow-up investigations were evaluated . In addition , the role of interval appendicectomy and conservative management in the pediatric population was also assessed . Results : The response rate for this survey was 74.7 % ( n = 74/99 ) . Over one-fifth ( n = 17 , 22.9 % ) routinely treat acute appendicitis conservatively , while another 14.8 % ( n = 11 ) consider this approach in selected cases . Main reasons for modified practice s included the presence of inflammatory phlegmon ( 75 % ) , delayed presentation ( 64 % ) , and recent evidence -based medicine developments ( 46 % ) . Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management ( 53 % ) . Alternatively , combinations of antibiotics were also utilized . One-third felt interval appendicectomy was warranted , while one-fifth supported conservative management in the paediatric setting . The overwhelming majority ( > 95 % ) advocate follow-up colonoscopy ± computed tomography in any patient aged > 40 years managed conservatively . Conclusion : Considerable variation in management of uncomplicated appendicitis  remains in Irel and despite growing evidence suggesting that the non-operative approach is safe . Reasons for adopting a conservative management practice have been identified and reflect the exp and ing literature on this subject Uncomplicated appendicitis may resolve spontaneously or require treatment with antibiotics or appendicectomy . The aim of this r and omized trial was to compare the outcome of a non‐antibiotic management strategy with that of antibiotic therapy in uncomplicated appendicitis A prospect i ve r and omized clinical trial was performed to determine the efficiency of single-dose antibiotic prophylaxis in preventing septic complications after appendectomy . The infection rate increased significantly in the control group without antibiotic prophylaxis ( 9.3 % to 20.3 % ) . Older patients with severe appendicitis had more advantages from the prophylaxis than younger ones . We have suggested to perform antibiotic prophylaxis individually only in those patients with high risk of septic complications after appendectomy BACKGROUND / PURPOSE Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration , operative timing , drain utilization , and wound closure . For 2 decades at the authors ' institution , patients were treated with ampicillin , gentamicin , and clindamycin for 10 inpatient days , with drains in the abdomen , result ing in lower complication rates than most other published series . Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes . In addition , there are little prospect i ve data on clinical outcomes . The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aim ed at decreasing cost and length of stay in our protocol were instituted . METHODS The authors monitored prospect ively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period . Patients received a single antibiotic , piperacillin-tazobactam , intravenously for 10 days . They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met . Other practice s from our earlier protocol were continued , including immediate operation , placement of Penrose drains , and primary wound closure . RESULTS Of 150 patients treated on our protocol , major complications included intraabdominal abscess in 5 ( 3.3 % ) , cecal fistula in 2 ( 1.3 % ) , phlegmon in 3 ( 2.0 % ) , wound infection in 4 ( 2.7 % ) , and no small bowel obstructions requiring operation . None of these complications , nor their aggregate , were significantly more common than those reported in 373 patients treated over 11 years on the authors ' prior protocol ( chi2 , P > .05 ) . CONCLUSIONS Prospect i ve outcome analysis of our protocol shows that a single broad-spectrum antibiotic ( allowing portions of therapy to be delivered less expensively on an outpatient basis ) effectively can treat postoperative appendicitis with very few infectious complications . These outcome data provide baseline against which future protocol s can be compared . All treatment modifications aim ed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised The editors of the Journal of Gastrointestinal Surgery as well as the SSAT Board of Directors have retracted the article Malik , A.A. & Bari , S.U. Conservative management of  acute appendicitis . J Gastrointest . Surg 13 , 966–970 ( 2009 ) since significant portions of the article were published earlier in the following articles : Eriksson , S. & Granstrom , L. R and omized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis . Br J Surg 82 , 166–169 ( 1995 ) . Horton , M.D. , Counter , S.F. , Florence , M.G. & Hart , M.J. A prospect i ve trial of computed tomography and ultrasonography for diagnosing  appendicitis in the atypical patient . Am J Surg 179 , 379–381 ( 2000 ) PURPOSE Although many patients receive antibiotic therapy for uncomplicated appendicitis , the relatively high treatment failure and recurrence rates are problematic . We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm , have better outcomes . The purpose of this prospect i ve non-r and omized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm . METHODS Over 2 years , we enrolled 119 patients who initially received antibiotic therapy .  The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis . Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively . We evaluated the rates of treatment failure , peritonitis , and recurrence . RESULTS Nine patients ( 7.6 % ) failed to respond to initial antibiotic therapy , and 6 had true appendicitis after subsequent surgery . Two patients had complicated appendicitis ( peritonitis ) , but no patient displayed intra-abdominal abscess postoperatively . During a median follow-up period months of 14 months , 14 patients ( 12.7 % ) experienced recurrence . CONCLUSIONS Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm Acute appendicitis continues as a medical challenge with newer approaches failing to improve diagnostic accuracy . The role of antibiotics in acute nonperforative appendicitis ( NPA ) remains unclear . In 175 patients studied at two hospitals , preoperative guidelines were used to exclude perforative appendicitis . Nevertheless , 14 % of patients were found to have this condition . Surgeon 's reports significantly underestimated the diagnosis when compared with the pathologists ' reports . Antibiotic prophylaxis in 122 patients with NPA was studied prospect ively comparing ceftizoxime ( CTZ ) , cefam and ole ( CFM ) , and placebo ( PLA ) . Ceftizoxime decreased the infection rate compared with PLA ( 0 vs. 8 ; P less than .01 ) . Use of antibiotics ( CTZ or CFM ) result ed in decreased infections when compared with PLA ( 3 vs. 8 ; P less than .01 ) and fewer days of hospitalization ( 3.8 vs. 5.4 d , P less than .005 ) . Analysis of infection risk factors showed no correlations except for failure to administer antibiotics and the finding of a gangrenous appendix . Operative culture results had no predictive value for either infection or pathogen identification . It is recommended that all patients undergoing surgery for NPA be given 1 d of antibiotic prophylaxis Abstract A post-hoc analysis of data from a trial of complicated intra-abdominal infection was performed to compare the demographic and disease characteristics of patients with complicated appendicitis to those whose primary infection involved other intraabdominal sites , assess the impact of site of primary infection on outcome , and compare the efficacy and safety of ertapenem 1 g daily with piperacillin-tazobactam 3.375 g every 6 h for treatment of complicated appendicitis . Compared with patients who had primary infection of the colon or another site in the abdomen , patients with complicated appendicitis were younger , had less severe disease ( based on lower APACHE II score and lower proportion with generalized peritonitis ) , and were less likely to be managed by percutaneous drainage of an abscess or to have a postoperative infection . Patients with complicated appendicitis were more likely to have a favorable outcome than were patients with infection of the colon ( OR , 3.02 ; 95 % CI , [ 1.54 - 5.90 ] ; P = .001 ) . At the test-of-cure assessment , 109/123 ( 88.6 % ) microbiologically evaluable patients with complicated appendicitis who received ertapenem and 102/113 ( 90.3 % ) who received piperacillin-tazobactam had a favorable combined clinical and microbiologic outcome . The frequency and severity of drug-related adverse events were similar in the two treatment groups A prospect i ve r and omized clinical trial was performed to determine the efficiency of single-dose antibiotic prophylaxis in preventing septic complications after appendectomy . The infection rate increased significantly in the control group without antibiotic prophylaxis ( 9.3 % to 20.3 % ) . Older patients with severe appendicitis had more advantages from the prophylaxis than younger one . We have suggested to perform antibiotic prophylaxis individually only in those patients with high risk of septic complications after appendectomy IMPORTANCE An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis . OBJECTIVE To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography ( CT ) . DESIGN , SETTING , AND PARTICIPANTS The Appendicitis Acuta ( APPAC ) multicenter , open-label , noninferiority r and omized clinical trial was conducted from November 2009 until June 2012 in Finl and . The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan . Patients were r and omly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period . INTERVENTIONS Patients r and omized to antibiotic therapy received intravenous ertapenem ( 1 g/d ) for 3 days followed by 7 days of oral levofloxacin ( 500 mg once daily ) and metronidazole ( 500 mg 3 times per day ) . Patients r and omized to the surgical treatment group were assigned to undergo st and ard open appendectomy . MAIN OUTCOMES AND MEASURES The primary end point for the surgical intervention was the successful completion of an appendectomy . The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period . RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group . Of 273 patients in the surgical group , all but 1 underwent successful appendectomy , result ing in a success rate of 99.6 % ( 95 % CI , 98.0 % to 100.0 % ) . In the antibiotic group , 70 patients ( 27.3 % ; 95 % CI , 22.0 % to 33.2 % ) underwent appendectomy within 1 year of initial presentation for appendicitis . Of the 256 patients available for follow-up in the antibiotic group , 186 ( 72.7 % ; 95 % CI , 66.8 % to 78.0 % ) did not require surgery . The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0 % ( 95 % CI , -31.6 % to ∞ ) ( P = .89 ) . Given the prespecified noninferiority margin of 24 % , we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery . Of the 70 patients r and omized to antibiotic treatment who subsequently underwent appendectomy , 58 ( 82.9 % ; 95 % CI , 72.0 % to 90.8 % ) had uncomplicated appendicitis , 7 ( 10.0 % ; 95 % CI , 4.1 % to 19.5 % ) had complicated acute appendicitis , and 5 ( 7.1 % ; 95 % CI , 2.4 % to 15.9 % ) did not have appendicitis but received appendectomy for suspected recurrence . There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients r and omized to antibiotic treatment . CONCLUSIONS AND RELEVANCE Among patients with CT-proven , uncomplicated appendicitis , antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy . Most patients r and omized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period , and those who required appendectomy did not experience significant complications . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01022567 BACKGROUND / PURPOSE Imaging techniques are used widely to diagnose appendicitis . However , the negative appendectomy rate remains at about 15 % . The authors assessed ultrasound-based decision making in the treatment of acute appendicitis in children . METHODS The authors prospect ively studied 165 consecutive children ( 3 to 15 years old ) evaluated for appendicitis . Diagnosis and treatment were based solely on ultrasound scan findings . Criterion for appendicitis was a diameter exceeding 6 mm . Severity was classified into 4 grade s based on the appearance of intramural appendiceal structure . Patients with grade s I or II received antibiotic therapy . Patients with grade s III or IV underwent appendectomy . RESULTS Ultrasound scan diagnosed appendicitis in 93 children ( grade I , 7 ; grade II , 17 ; grade III , 41 ; and grade IV , 28 ) . All but 2 patients with grade s I or II underwent  antibiotic therapy  without complication . All grade s III or IV patients underwent appendectomy . There was no negative appendectomy among 76 appendectomies during this period . Ultrasound-based prediction of severity was correct in 67 cases ( 88 % ) . Ultrasonography identified other pathology in 39 . CONCLUSIONS Ultrasonography in children can not only visualize all inflamed appendices but also predict severity of disease . Treatment based entirely on ultrasound scan identified patients who required surgery for severe appendicitis and permitted successful conservative treatment for mild appendicitis Abstract Aim The main goal of our study was to assess a 7 days long course of antibiotics for acute uncomplicated appendicitis . Material s and Methods From March 2014 to November 2015 , all patients diagnosed with acute appendicitis have been considered to be treated by only antibiotics .  Inclusion criteria included clinical ( tenderness ) , biological ( C‐reactive protein [ CRP ] < 50 ) , and radiological features ( diameter > 6 mm ) . All patients were treated with intravenous amoxicillin and clavulanic acid ( 100 mg/kg/day ) for 2 days ( six doses ) . At the end of the treatment , clinical and para clinical examinations included blood sample s at day 7 and ultrasound ( US ) scan at 3 months . Results A total of 166 patients were treated and followed up prospect ively during the study period . Mean age at diagnosis was 10.8 ± 0.6 years . All children , but four were discharged with a clinical improvement after 48 hours and six intravenous antibiotics injection according to our protocol . Four children required surgery during the initial hospitalization period . Initial ultrasound scan showed a mean diameter of 7.85 ± 1.6 mm , with inflamed fat in 124 patients ( 74.7 % ) . At Day 7 , the diameter was 5.2 ± 1.6 mm ( p < 0.0001 ) . During a median follow‐up of 18.8 months ( 3.5‐18 ) , 22 patients ( 13.25 % ) had to be managed for a novel episode of acute appendicitis after a median period of 138 days ( 13‐270 ) . None had to be managed for a complicated appendicitis . Conclusion Non‐operative treatment ( NOT ) is a safe alternative for the management of uncomplicated acute appendicitis in children . Further study should be conducted to determine relapse risk factors A prospect i ve study on the management of severe acute appendicitis with gangrene and perforation was carried out using protocol s that included schematized treatment . The schemes emphasized adequate preoperative treatment , meticulous operative technique of peritoneal toileting , generous use of appropriate antibiotics in combinations , and early grade d patient 's ambulation in the postoperative period . The average hospital stay was seven days , wound infection was of mild degree and less than 1 % , and there was a low morbidity . Follow-up has shown no serious complications
The need for crossover in management and recurrent appendicitis were low among all studies .
For those patients who ultimately required surgery , no increased complications were observed .
Antibiotics may be safely recommended in patients with high surgical risk , such as the elderly or those with multiple comorbidities
AIM To review outcomes of  surgical and antibiotic management of acute appendicitis .