Antibiotics Viable Long-Term Option for Uncomplicated Acute Appendicitis: JAMA
Finland: A 10-year follow-up of adults with uncomplicated acute appendicitis initially treated with antibiotics shows acceptable rates of recurrence and subsequent appendectomy. These long-term outcomes support antibiotics as a viable and safe alternative to surgery for selected adult patients with uncomplicated appendicitis, allowing non-operative management when clinically appropriate.
While appendectomy has long been considered the standard treatment for acute appendicitis, growing interest in conservative management has prompted evaluation of antibiotics as a primary therapy, particularly in uncomplicated cases. Short- and mid-term randomized trials have previously demonstrated the feasibility of this approach, but robust long-term data have been limited. The latest findings from the APPAC (Appendicitis Acuta) randomized clinical trial, published in JAMA, now provide valuable insight into outcomes over a full decade.
Paulina Salminen from the Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, and colleagues reported the 10-year observational follow-up of adults enrolled in the original APPAC trial. The study was conducted across six Finnish hospitals between 2009 and 2012 and included 530 patients aged 18 to 60 years with computed tomography–confirmed uncomplicated acute appendicitis. Participants were randomized to undergo either open appendectomy or antibiotic therapy, with the current analysis focusing on long-term outcomes among those initially treated with antibiotics.
Antibiotic therapy consisted of three days of intravenous ertapenem followed by seven days of oral levofloxacin and metronidazole. At the 10-year mark, follow-up data were available for 98.4% of patients assigned to the antibiotic group, providing a comprehensive assessment of long-term recurrence and surgical intervention rates.
Key Findings:
- The 10-year true appendicitis recurrence rate after initial antibiotic treatment was 37.8%, based on histologically confirmed cases.
- The cumulative appendectomy rate in patients initially treated with antibiotics was 44.3%, meaning more than half avoided surgery over long-term follow-up.
- A substantial proportion of appendicitis recurrences occurred several years after the initial episode, highlighting the importance of long-term monitoring.
- The overall 10-year complication rate was significantly higher in patients who underwent appendectomy compared with those treated with antibiotics (27.4% vs 8.5%).
- Surgical complications included both early and late postoperative events, while complications related to antibiotic therapy were uncommon.
- Long-term quality of life and patient satisfaction were comparable between the antibiotic and appendectomy groups.
- Imaging-based follow-up did not identify a concerning rate of missed appendiceal tumors in patients initially managed with antibiotics.
Taken together, these findings reinforce antibiotics as a reasonable first-line option for selected adults with uncomplicated acute appendicitis. Although recurrence and delayed appendectomy remain possible, the long-term safety profile, lower complication rates, and comparable quality of life outcomes support shared decision-making and individualized treatment selection. The authors conclude that non-operative management can be confidently offered when clinically appropriate, backed by durable evidence extending to 10 years of follow-up.
Reference:
Salminen P, Salminen R, Kallio J, et al. Antibiotic Therapy for Uncomplicated Acute Appendicitis: Ten-Year Follow-Up of the APPAC Randomized Clinical Trial. JAMA. Published online January 21, 2026. doi:10.1001/jama.2025.25921
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