I disagree with the conclusion of the editorialist that treatment with antibiotics can only be done under the protocol of a clinical trial. Studies have shown that treatment with antibiotics is 90% effective. In an era where surgery is expensive, deductibles are high, and patient autonomy is paramount in the treatment decision making process, the patient should be given a choice of treatment and the ultimate decision should be weighed on the analysis of the risks and benefits. If this was me, I would rather give the antibiotics a try.
Antibiotics Fail More Often Than Appendectomy for Pediatric Appendicitis — Physician’s First Watch
Antibiotics Fail More Often Than Appendectomy for Pediatric Appendicitis
By Kelly Young
Edited by Jaye Elizabeth Hefner, MD
Antibiotics may be effective for pediatric appendicitis, but they have a higher failure rate than appendectomy, particularly in the presence of appendicolith, according to a meta-analysis in JAMA Pediatrics.
Researchers studied five trials comparing antibiotics and appendectomy in 400 patients aged 5–18 years with image-confirmed, acute, uncomplicated appendicitis.
For patients initially given antibiotics, the early success rate — i.e., symptom resolution without surgery within 48 hours or appendicitis recurrence within 1 month — was 90%. In comparison, over 99% of appendectomies were successful. Accordingly, treatment failure was much more common with antibiotics than with appendectomy (risk ratio, 8.92). For patients who had appendicolith, the risk for treatment failure with antibiotics was even higher (risk ratio, 10.43).
Editorialists conclude: "Nonoperative treatment remains an experimental proposition meriting ongoing consideration as a treatment strategy for uncomplicated appendicitis in children. This therapeutic option should only be offered to pediatric patients under protocol in the setting of a clinical trial."
Reader Comments (2)
What isn't clear is whether the editorial writers were surgeons or internists. If ninety percent of patients without fecaliths can avoid even the least invasive surgery and anesthesia risks with antibiotics , and no bureaucratic bean counters rule one must have a trial of antibiotics regardless of presentation, I don't think that they should be dismissed out of hand as "experimental". Acute abdomens clearly can't wait for surgical intervention, but not every presentation is so obvious. Understand your patient's pathology first.