Oral Antibiotics Effective in Treating Uncomplicated Appendicitis: JAMA

Recent findings from the Appendicitis Acuta II (APPAC II) trial indicated that treating uncomplicated acute appendicitis with just oral antibiotics may not be inferior to a combined regimen of intravenous and oral antibiotics. This study published in the Journal of American Medical Association offers critical look at the potential of antibiotic monotherapy to replace more traditional treatments that involved surgery.

This research was conducted across nine university and central hospitals in Finland and involved a substantial cohort of 599 patients. This secondary analysis evaluate the effectiveness of oral antibiotic monotherapy against a combined approach of intravenous and oral antibiotics in the patients with computed tomography (CT)-confirmed uncomplicated acute appendicitis. The participants included in the trial were between 18 to 60 years and were administered either oral moxifloxacin or a combination of IV ertapenem followed by oral levofloxacin and metronidazole.

Over a three-year follow-up period, the primary measure of success was defined by the resolution of appendicitis symptoms, discharge without the need for surgical intervention and the absence of recurrence. At the year 3 mark, the data revealed a slight difference in treatment success rates of 63.4% for the oral monotherapy group and 65.2% for the individuals who received combined therapy.

The noninferiority margin was not definitively exceeded, as the difference in treatment success rates between the two groups was marginal at -1.8 percentage points. Based on the individual patient scenarios and healthcare provider discretion, this indicates that oral antibiotics alone might still be a potential alternative to more invasive methods, despite being slightly less effective.

The study observed no significant differences in secondary outcomes such as late appendicitis recurrence, treatment-related adverse events, quality of life, hospital stay duration or length of sick leave. These findings suggest that both treatment protocols are similarly safe and tolerable for patients.

The results did not robustly demonstrate the noninferiority of oral antibiotic monotherapy when compared to the combined therapy approach. This calls for further investigations to solidify the role of oral antibiotics in treating uncomplicated appendicitis with the potential benefits of avoiding surgery and its associated risks. These findings imply that the need for surgical interventions in uncomplicated appendicitis cases potentially reduced and shifting the treatment towards a less invasive approach.

Source:

Selänne, L., Haijanen, J., Sippola, S., Hurme, S., Rautio, T., Nordström, P., Rantanen, T., Pinta, T., Ilves, I., Mattila, A., Rintala, J., Marttila, H., Meriläinen, S., Laukkarinen, J., Sävelä, E.-L., Paajanen, H., Grönroos, J., & Salminen, P. (2024). Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis. In JAMA Surgery. American Medical Association (AMA). https://doi.org/10.1001/jamasurg.2023.5947