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Antibiotic treatment of acute appendicitis mostly safe for children

An analysis of several studies including 404 paediatric patients suggests antibiotic treatment for acute uncomplicated appendicitis is safe and effective in the majority of patients – but the risk that antibiotic treatment would fail increased in patients with appendicolith, a calcified deposit in the appendix, according to researchers in China.

Acute appendicitis is one of the most common pediatric emergencies. Several randomised clinical trials have shown the effectiveness and safety of non-operative treatment for acute appendicitis in adults with uncomplicated disease where an inflamed appendix is intact.

But the clinical scenario of acute appendicitis in pediatric patients is different from that in adults and treatment decisions for children are more difficult.

Dr Yuan Li, of Sichuan University in Chengdu, China, and co-authors conducted a meta-analysis to compare antibiotic treatment with appendectomy to treat uncomplicated acute appendicitis in pediatric patients. The meta-analysis of five studies included 404 paediatric patients (between the ages of 5 and 15) with uncomplicated appendicitis. The authors summarised the characteristics of the patients in the five studies; 168 were in the antibiotic treatment group and 236 were in the appendectomy group.

The authors report nonoperative treatment was successful in 152 of 168 patients (90.5%). Of the 16 patients in the antibiotic group, 11 had an appendectomy within 48 hours and 5 patients had recurrence of appendicitis after 1-month follow-up, according to the report.

The study has limitations including that only one randomised clinical trial and four other cohort studies were included.

"This meta-analysis shows that antibiotics as the initial treatment for paediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith," the article concludes.

Abstract
Importance: Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial.
Objective: To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients.
Data Sources: The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial.
Study Selection: Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days.
Data Extraction and Synthesis: Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated.
Main Outcomes and Measures: The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection.
Results: A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%).
Conclusions and Relevance: This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.

Authors
Libin Huang, Yuan Yin, Lie Yang, Cun Wang, Yuan Li, Zongguang Zhou

[link url="https://www.sciencedaily.com/releases/2017/03/170327131207.htm"]JAMA material[/link]
[link url="http://jamanetwork.com/journals/jamapediatrics/article-abstract/2613402"]JAMA Pediatrics abstract[/link]

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