Turku, Finland—Most patients—about 60%—who had uncomplicated acute appendicitis and were treated with antibiotics didn’t require appendectomy in a 5-year follow-up, a randomized clinical trial found.

A report in JAMA notes that the clinical trial included 273 patients who underwent an appendectomy and 257 patients who were initially treated with antibiotics for uncomplicated acute appendicitis. Just 100 of the patients initially treated with antibiotics underwent appendectomy during the 5-year study period, and 15 of those had surgery during an initial hospitalization. 

According to Finnish researchers from the University of Turku, their findings indicate that antibiotics might be a feasible alternative to surgery for patients with uncomplicated acute appendicitis.

While short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis, long-term outcomes have been unknown. To remedy that, the researchers sought to determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis.

To do that, the study team conducted a 5-year observational follow-up of patients in the Appendicitis Acuta multicenter clinical trial comparing appendectomy with antibiotic therapy. For that study, 530 patients aged 18 to 60 years who had computed tomography–confirmed uncomplicated acute appendicitis were randomized to either undergo an appendectomy or receive antibiotic therapy.

The initial trial lasted until June 2012 in Finland, with follow-up in September 2017. The current analysis assessed 5-year outcomes only for the group of patients treated with antibiotics alone. Those patients had received antibiotic therapy with IV ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole.

Results indicate that 70 patients who initially received antibiotics had to undergo appendectomy within the first year (27.3% [95% CI, 22.0%-33.2%]; 70/256), with 30 additional antibiotic-treated patients (16.1% [95% CI, 11.2%-22.2%]; 30/186) having appendectomy between 1 and 5 years later. 

The cumulative incidence of appendicitis recurrence was 34.0% (95% CI, 28.2%-40.1%; 87/256) at 2 years, 35.2% (95% CI, 29.3%-41.4%; 90/256) at 3 years, 37.1% (95% CI, 31.2%-43.3%; 95/256) at 4 years, and 39.1% (95% CI, 33.1%-45.3%; 100/256) at 5 years, according to the report.

Researchers noted that, of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis, 76 had uncomplicated appendicitis, two  had complicated appendicitis, and seven did not have appendicitis. 

By 5 years, the overall complication rate—surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms—was 24.4% (95% CI, 19.2%-30.3%) (n = 60/246) in the appendectomy group and 6.5% (95% CI, 3.8%-10.4%) (n = 16/246) in the group receiving only antibiotics—a 17.9% difference.

Length of hospital stay didn’t differ between the two groups, but surgical patients had to take an average of 22 more days of sick leave, the researchers wrote. “Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within five years was 39.1%,” the study authors concluded. “This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis.”

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