For uncomplicated appendicitis when is initial antibiotic therapy a reasonable first line option?
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- Answered 17 Jun 2019 Conflict of interest declaration: None Meta-analysis 2019: https://link.springer.com/content/pdf/10.1007%2Fs00384-019-03296-0.pdf "The evaluation of the included studies shows that treatment success was higher in the surgical group than in the antibiotic group, in which more than a third of patients required appendectomy for initially persistent appendicitis or recurrent appendicitis within 1 year from the initial antibiotic treatment." This paper also reports that if absence from work is an issue for the patient, antibiotic treatment can be offered, but the patients must be informed that recurrence before 1 year is possible. The authors conclude that both options are safe, so an informed shared decision is recommended. A recent RCT (257 patients in the antibiotic arm) showed that 72.7% of them did not require surgery. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Link: https://www.ncbi.nlm.nih.gov/pubmed/26080338 A much older DARE review concludes that: "The authors stated that there is evidence to support the safe use of antibiotic therapy alone in selected patients presenting with acute appendicitis where perforation or peritonitis is not suspected". A clinical trial is ongoing: https://clinicaltrials.gov/ct2/show/NCT03236961 I dare say that further research should focus on the clinical characteristics of the patients that did not respond to antibiotics and eventually needed surgery.