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Antibiotics may be a possible alternative to surgery for patients with uncomplicated acute appendicitis, 5-year follow-up data from a randomized trial.
"Long-term follow-up of patients with uncomplicated acute appendicitis suggests that initial treatment with antibiotics rather than surgery could be a feasible alternative," write Paulina Salminen, MD, PhD, of the University of Turku, in a statement. Finland, and his colleagues. The researchers published the results online today. JAMA.
Although appendectomy has been the mainstay of the treatment of acute appendicitis for over 100 years, recent advances in diagnostic imaging and antibiotic therapy have allowed clinicians to view antibiotic therapy as a viable alternative strategy in some case.
In a recent randomized clinical trial, Salminen and colleagues found that 73% of all patients with uncomplicated acute appendicitis who received antibiotics alone did not require surgery at one year of follow-up. However, questions remained about the long-term outcomes for these patients.
With this in mind, Salminen and his colleagues sought to study the long-term recidivism rate among trial participants. The randomized trial of Appendicitis Acuta was conducted in 6 hospitals in Finland and included 530 adults (329 men, 201 women) with uncomplicated acute appendicitis. Of these, 273 had appendicectomy (median age 35) and 257 initially received antibiotic therapy (median age 33).
With 5 years of follow-up, 3 patients died: 2 in the appendectomy group and 1 in the antibiotic group. However, none of the deaths was considered to be related to the trial.
Of the 257 patients who initially received antibiotics, 100 underwent appendectomy during follow-up. Of these, 70 had recurrent appendicitis in the year following the first episode (27.3%, 95% confidence interval). [CI], 22.0% – 33.2%; 70/256), and 30 patients required appendicectomy between 1 and 5 years (16.1%, 95% CI, 11.2% – 22.2%, 30/186).
The cumulative incidence of recurrent appendicitis in patients who initially received antibiotics alone 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 age 4 and 39.1% (95% CI, 33.1% – 45.3%; 100/256) at age 5
"Nearly 2/3 of all patients who initially had uncomplicated appendicitis were successfully treated with antibiotics alone and those who eventually developed recurrent disease did not experience any adverse effects related to the delay of the treatment." 39, appendectomy, "write the authors.
"These results demonstrate the feasibility of treating appendicitis with antibiotics and without surgery," conclude Salminen and colleagues.
In an accompanying editorial, Edward H. Livingston, MD, deputy editor of JAMA, points out that one of the most important discoveries of this study is that patients in the group of antibiotics who ultimately needed a surgical procedure did not present any major complication because of a delayed surgery.
"The results of the [Appendicitis Acuta] The trial refutes the idea that uncomplicated acute appendicitis is a surgical emergency, "he points out." Because access to a surgeon is not always available. " these results may have implications in many contexts and in different countries.
Future studies should focus on factors such as the optimal regimen to be used for the antibiotic treatment of appendicitis, Livingston says, as well as how to manage recurrent appendicitis suspected in patients who initially receive antibiotics alone.
In the AAPAC trial, patients in the antibiotic group received intravenous eryapenem (1 g / day) for 3 days in the hospital, followed by 7 days of levofloxacin (500 mg a day). times a day) and metronidazole (500 times 3 times a day). However, Livingston explains that this diet is probably more aggressive than necessary and should be re-evaluated.
The next step of the research on appendicitis should extend to the results of this trial to improve the nonsurgical treatment of appendicitis, he continued. "Additional studies should be designed using a non-inferiority approach, comparing different antibiotic approaches to those used [Appendicitis Acuta] study, "he concluded.
This study was supported by the Mary and Georg C. Ehrnrooth Foundation, a government research grant (EVO Foundation) awarded to the Turku University Hospital Center and a research grant from the University of Turku. Salminen said he received personal fees for the Merck, Lilly and Orion Pharma conferences. The other authors and the editorialist did not report any financial conflict of interest.
JAMA. Posted online September 25, 2018.
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