Appendicitis Treatment With Antibiotics

One of the options for managing mild to moderately severe appendicitis that is unlikely to be associated with major perforation of the appendix and complications is treatment with antibiotics but no surgery. Patients often resolve their inflammation with antibiotics alone, but it has not been clear how many respond to antibiotics alone and what happens to them in the longer term, that is, over the ensuing weeks, months, or years. Specifically, does appendicitis recur and/or is surgery ultimately required?

A Swedish study looked specifically at these questions. The study randomized 252 men ages 15-50, to surgery or antibiotic treatment alone, excluding patients with a high suspicion of major perforation or complications. The antibiotic-treated patients received intravenous antibiotics for two days and then were switched to oral antibiotics for 10 days. Antibiotic-treated patients who did not respond within 24 hours to the antibiotics went to surgery immediately.

Fifteen antibiotic-treated patients did not respond to antibiotics alone (12% of patients) and went to surgery immediately. The numbers of patients who experienced a major perforation identified at the time of surgery were the same in the surgery-treated group and the antibiotic treated group, 5%, suggesting that waiting 24 hours to see if antibiotics alone would work did not lead to more perforations. Most of the antibiotic-treated patients (88%) recovered without surgery, demonstrating that antibiotics are very effective for treating mild to moderate appendicitis. Within the following five years, however, almost one-quarter (24%) of the patients who responded to antibiotics alone developed a second episode of appendicitis with most of the recurrences during the first year. (All of the recurrences were treated with surgery.)

A rate of recurrence of 24% is not high, but it also is not negligible. How can the findings of this study be used? First, the findings suggest that if there are reasons to postpone surgery, antibiotics alone are a satisfactory way to treat mild to moderate appendicitis without complications. Whether or not a 24% rate of recurrence is enough reason to undergo elective surgery--after the appendicitis has resolved with antibiotics alone and before it has a chance to recur--probably will be a choice made by individual patients. For some, the risk of recurrence will be acceptable and they will not opt for elective surgery. For others the risk will be too great not to undergo elective surgery. It is important to remember that the results of this study apply only to younger patients (ages 15-50) with mild to moderate, uncomplicated appendicitis. Although the study was limited to men, there is no reason to believe that the results would be different in women.