Published in JAMA: The Journal of the American Medical Association

This full article is available on the publisher's site-

https://jamanetwork.com/journals/jama/fullarticle/2768929

Expert comment By David Rakel MD, FAAFP
Esther Millard Endowed Professor, University of Wisconsin School of Medicine & Public Health; Chair, Department of Family Medicine and Community Health, University of Wisconsin, Madison, Wisconsin

Non-operative appendicitis treatment

This study shows that a trial of antibiotics reduced the need for surgery in 1068 children by 67% after 1 year. Here is what you need to know to provide this service.

Criteria for antibiotic therapy

• Imaging with ultrasound, CT, or MRI showing an appendix size of 1.1 cm or less without abscess, fecalith, or phlegmon
• A white blood cell count between 5000 and 18,000
• Abdominal pain for less than 48 hours prior to starting antibiotics
• Absence of diffuse abdominal peritonitis  

Antibiotic protocol

A minimum of 24 hours of IV antibiotics using piperacillin tazobactam, 2 g/0.25 g: 3.375 g piperacillin tazobactam every 6 hours (dose reduced for <40 kg).

Or if penicillin-allergic, ciprofloxacin, 30 mg/kg/d divided every 8 hours up to 1200 mg/d, and metronidazole, 30 mg/kg/d divided every 6 hours up to 500 mg per dose. 

If there was improvement after 24 hours, patients were switched to oral antibiotics with the first dose given in the hospital. The piperacillin tazobactam group was given amoxicillin-clavulanate and the ciprofloxacin and metronidazole group were switched to the oral forms of these drugs. The antibiotics were continued for a total of 7 days.

Failure of antibiotic treatment was determined by no improvement of abdominal pain or deterioration after 24 hours.

Benefits of antibiotic treatment compared with surgical treatment

• Fewer days of disability (6.6 vs 10.9 after 1 year)
• Fewer surgical complications
• Less risk of performing surgery for a normal appendix (rate = 7.5%)

Downside of antibiotic treatment

• More antibiotic side effects (2.4% vs 0.6%)
• More readmissions to the hospital (23% vs 2.9%)
• Longer hospital stays (1.5 days vs 1.0 days)

This study supports shared decision–making with clinicians and affected families as either antibiotics or surgery can be effective options.