Antibiotics Over Surgery for Initial Treatment of Appendicitis in Children

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A meta-analysis study published in JAMA Pediatrics investigated the effectiveness and safety of antibiotic treatment over surgical intervention in children with uncomplicated appendicitis.

 

The appendix is a blind-ended tube connected to the cecum, the initial part of the large intestine. Appendicitis is an inflammation of the appendix, which is acute and painful condition felt at the right side of the abdominal. Acute appendicitis is one of the most common reasons for visits to the emergency and a surgical appendectomy (first reported in 1889) is the standard treatment.  However, surgical intervention comes with a risk of post-surgical complications and may be avoided with antibiotic treatment in uncomplicated cases.

Several Randomized Clinical Trials (RCT) have proven that non-operative treatment may be an effective and safe alternative to surgical intervention in adult patients with uncomplicated appendicitis, with the success rates ranging from 63 to 85%.  There are anatomical and pathophysiological differences between adults and pediatric patients, and results from clinical studies on adult population cannot be applied to children. An article published in JAMA Pediatrics presents results of a meta-analysis (statistical analysis combining results of many studies) of data from multiple studies investigating the effectiveness and safety of antibiotic versus surgical intervention for pediatric patients with uncomplicated appendicitis.

To reduce bias, a search for articles was performed by two independent reviewers using a defined set of terms to identify clinical studies on appendicitis in pediatric groups. The data from 5 studies describing the treatment of a total of 404 patients (ages 5-18) with uncomplicated appendicitis was evaluated. Of the 404 patients, 168 received antibiotics and 236 underwent appendectomy. Patients with complicated appendicitis were not included in the study. For the antibiotic group, successful treatment was defined as resolution of symptoms without need for surgery during 48h, and for the surgical group was an operation without negative appendectomy findings or need for reoperation. Study analysis demonstrates the initial success rate of antibiotic treatment as high as 90.5%, with only 16 out of 168 patients failing to respond to antibiotics. The failure of antibiotic treatment was associated with appendicolith diagnosis, another acute appendix condition. Follow-up analysis one year later revealed that 26% of the patients needed surgical intervention due to treatment failure, histological reoccurrence or parents’ demand.

Although 26% of the patients needed appendectomy a year later, there is a significant percentage (74%) of patients who recovered with no need for surgical intervention. In addition to the safety aspect, non-surgical treatment is associated with lower cost in terms of hospitalizations and involvement of medical personnel. Additional clinical studies on larger groups of patients addressing the duration, dose and type of antibiotics treatment are needed. In summary, antibiotics treatment for uncomplicated appendicitis in children has a high initial success rate while avoiding potential surgical complications and costs.

 

Written By: Bella Groisman, PhD

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