Appendicitis is nearly always treated with surgical removal of the appendix, making it the most common cause of emergency surgery in children, but growing evidence shows that for those who want to avoid surgery, a course of antibiotics may be a valid alternative.
When Aria Gibson (10) had a stomach ache after attending a party, her mother, Aubrey, thought it was from the pizza and sweets, and told her to lie down. But when her daughter woke up, her stomach hurt so much she couldn’t stand. And she was running a high fever.
Gibson took her to the hospital, where, after an evaluation and an ultrasound, the doctors diagnosed Aria with appendicitis. Gibson and Aria were both devastated. Aria was scheduled to be in her school play just three days later, and her parents had been saving for two years for a trip to Disney World. An appendectomy meant no school play, and maybe no Disney.
But the doctors at Nationwide Children’s Hospital offered her another option: they could try treating Aria with antibiotics. She’d receive the drugs intravenously in the hospital, and if her symptoms improved, she could go home. Her only management would be a course of oral antibiotics afterward. Gibson didn’t hesitate.
“We were excited to try it,” she said. “It worked and we were able to go to Disney World.”
The Washington Post reports that Aria, who is now 21 and in nursing school, was one of the early patients enrolled in the first trial of whether antibiotics are an effective first-line treatment for appendicitis.
“It is good enough and safe enough and effective enough that we owe people the choice,” said Peter Minneci, who ran the study in which Aria was enrolled and is now chair of surgery at Nemours Children’s Health in Delaware.
Quietly effective
Though appendectomies have been the gold standard of care since before the turn of the 20th century, doctors have been treating appendicitis with antibiotics since the 1950s, as soon as they became available, a “dark secret” in the surgery world, said David Flum, professor of surgery and director of the Surgical Outcomes Research Centre at the University of Washington.
A 1959 paper detailed the use of antibiotics to treat nearly 500 people (a mix of adults and children) with appendicitis. They were, and still are, often used in patients whose appendicitis is so advanced that surgery risks spreading the infection further. The military relied on antibiotics for servicemen who got appendicitis while in inaccessible locations, like submarines.
But the treatment didn’t get wider attention until the late 1990s and early 2000s, Flum said, when researchers began to collect data on how often antibiotics don’t work and found that failure was not as common as they thought.
Then came two large, randomised trials in adults. In the first, published in 2015, 257 adults received an antibiotic treatment. Seventy of those patients, or 27%, had to have an appendectomy within one year. But the rest were fine.
A second, larger study of 1 552 adults had similar results: 29% of the 776 people who received antibiotics underwent surgery within 90 days; 4% in the antibiotics group had serious adverse events, compared with 3% in the appendectomy group.
The New England Journal of Medicine published the results in 2020. The same year, the American College of Surgeons added non-operative management as an option in its guidelines for treating appendicitis.
It wasn’t a slam dunk, but the studies showed that antibiotics could be a good choice.
“There are now two treatments for appendicitis,” said Flum, the principal investigator in the second larger study. “And they both work.”
Collecting data has proved more difficult in children, largely because parents are – understandably – hesitant to test treatments on their children.
As Minneci was starting his trial in 2015, he asked an audience of 150 hospital staff on his grand rounds, which included paediatricians, surgeons and nurses, how many would be open to randomised treatment for their own appendicitis.
About half raised their hands, he recalled. But when he asked how many would make that same choice for their child? “None.”
Minneci worked around that by designing a trial that allowed parents to choose their child’s treatment. (He was also careful to enrol only kids who met certain criteria indicating their appendicitis wasn’t severe or the organ hadn’t ruptured.)
Ultimately, he and his colleagues across 10 children’s hospitals enrolled 1 068 children with appendicitis, 370 (35%) of whom chose antibiotics for their condition.
One year later, 33% of those children had had an appendectomy, according to results published in JAMA in 2020; 53 of them had surgery before leaving the hospital, either because their symptoms failed to improve or their caregiver changed their mind about treatment.
At the same time, another large trial was running at centres across the US and in Europe. Known as APPY, the study compared appendectomy to antibiotics in 978 children aged five to 16. It was the first large study that randomised families to their treatment option, ensuring that results weren’t biased due to parents of children with less severe illness being more willing to forgo surgery, says Shawn St Peter, surgeon in chief at Children’s Mercy Hospital in Kansas City, and APPY’s principal investigator.
Within a year, 33.8% of the children treated with antibiotics got surgery to remove their appendix, St Peter said, either they never improved, or they went home only to get appendicitis again sometime in the months after.
St Peter expects the full results to be published soon.
“What is important is what mom thinks of 33%,” St Peter said. “To some parents, that sounds like a ridiculously high number. And to some that sounds totally reasonable if we’re avoiding an operation today.”
Both approaches carry benefits and risks, surgeons say. Unlike antibiotics, surgery eliminates the chance of ever having appendicitis again. In rare cases, surgeons discover a precancerous or cancerous growth on the appendix, which could later become a bigger health threat.
Some people have bad reactions to antibiotics, such as diarrhoea or nausea, although, as Minecci points out, most people receiving surgery will get similar antibiotics.
Though appendectomies are considered one of the safest surgical procedures, surgery is still surgery and carries risks. Anesthesia always carries risks. And appendectomy is undoubtedly a more expensive treatment than antibiotics.
As the data have become clearer – antibiotics work, a decent amount of the time – the decision has, in some ways, become murkier. For many families, it will depend largely on how important they believe it is to avoid surgery, as well as which surgeon they see.
“It seems as though we are going to have this grey zone, that is open to interpretation, on what is the best way to treat this,” said Thomas Inge, surgeon-in-chief at Lurie Children’s Hospital of Chicago, who has not been involved in any of the trials.
For Inge, the existing data justify presenting both options to families. But when parents ask him what he recommends, what he would do if it were his child, he tends to say surgery. In his experience, most families aren’t open to a 30% chance of landing back in the emergency room.
His recommendation may change if long-term data ever show that fewer than 10% of people have a recurrence of appendicitis in five years, he added.
Children have more time left, than, say, a 60-year-old, in which their appendix may act up again. And because removing the appendix has been the go-to treatment for a first bout of appendicitis, there’s no long-term data on whether having it once increases the odds of getting it again.
Meanwhile, surgeons are eyeing ways to improve both treatments. Many children who receive appendectomies can go home the same day. It’s possible they could be treated with IV antibiotics in the emergency room and then go home with oral medication when their symptoms improve, without ever being admitted. (The 2015 trial in adults even has data showing appendicitis can resolve with no treatment at all, though that’s probably an impossible sell for kids, Minneci said.)
And with more time, both surgeons and parents may get more comfortable with the idea that appendicitis doesn’t equal appendectomy.
“It’s 130 years of that story being out there,” Flum said. “To reverse that story is going to take some time.”
JAMA Network article – Antibiotics on Par With Surgery for Appendicitis (Open access)
See more from MedicalBrief archives:
Antibiotics effective in 70% of appendix cases with no added risk – Duke study
Royal College Ireland: Surgery best for acute uncomplicated appendicitis
Antibiotics compared to surgery in treating appendicitis — Randomised trial
Antibiotics alone an alternative to surgery for appendicitis in children