J Pediatr Surg. 2010 Nov;45(11):2181-5.
Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review.
Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ; 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee.
Division of Pediatric Surgery, David Geffen School of Medicine at UCLA and Harbor-UCLA Medical Center, Box 709818, Los Angeles, CA 90095, USA. email@example.com
OBJECTIVE: The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.
DATA SOURCE: Data were obtained from PubMed, MEDLINE, and citation review.
STUDY SELECTION: We conducted a literature search using “appendicitis” combined with “antibiotics” with children as the target patient population. Studies were selected based on relevance for the following questions: (1) What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis? (2) For patients with perforated appendicitis treated with appendectomy: a. What perioperative intravenous antibiotics should be used? b. How long should perioperative intravenous antibiotics be used? c. Should oral antibiotics be used? (3) For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?
RESULTS: Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.
CONCLUSIONS: Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.
Surg Infect (Larchmt). 2008 Aug;9(4):481-8.
Surgery for appendicitis: is it necessary?
Division of Emergency Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California and Los Angeles County and USC Medical Center, Los Angeles, California, USA.firstname.lastname@example.org
BACKGROUND: Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored.
METHODS: Systematic review of published literature and derived expert opinion.
RESULTS: Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management.
CONCLUSIONS: Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for.
World J Surg. 2006 Jun;30(6):1033-7.
Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial.
Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, Rex L, Badume I, Granström L.
Department of Surgery, Karolinska Institutet at Danderyd Hospital, S-182 88, Stockholm, Sweden. email@example.com
• World J Surg. 2007 Mar;31(3):615; author reply 616.
• World J Surg. 2007 Apr;31(4):871-2.
BACKGROUND: Appendectomy has been the treatment for acute appendicitis for over 120 years. Antibiotic treatment has occasionally been used in small uncontrolled studies, instead of operation, but this alternative has never before been tried in a multicenter randomized trial.
PATIENTS AND METHODS: Male patients, 18-50 years of age, admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study. No women were enrolled by decision of the local ethics committee. If appendectomy was planned, patients were asked to participate, and those who agreed were randomized either to surgery or to antibiotic therapy. Patients randomized to surgery were operated on with open surgery or laparoscopically. Those randomized to antibiotic therapy were treated intravenously for 2 days, followed by oral treatment for 10 days. If symptoms did not resolve within 24 hours, an appendectomy was performed. Participants were monitored at the end of 1 week, 6 weeks, and 1 year.
RESULTS: During the study period 252 men participated, 124 in the surgery group and 128 in the antibiotic group. The frequency of appendicitis was 97% in the surgery group and 5% had a perforated appendix. The complication rate was 14% in the surgery group. In the antibiotic group 86% improved without surgery; 18 patients were operated on within 24 hours, and the diagnosis of acute appendicitis was confirmed in all but one patient, and he was suffering from terminal ileitis. There were seven patients (5%) with a perforated appendix in this group. The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14% during the 1-year follow-up.
CONCLUSIONS: Acute non-perforated appendicitis can be treated successfully with antibiotics. However, there is a risk of recurrence in cases of acute appendicitis, and this risk should be compared with the risk of complications after appendectomy.
J Chir (Paris). 2009 Oct;146 Spec No 1:17-21. Epub 2009 Oct 28.
[Can acute appendicitis be treated by antibiotics and in what conditions?].
[Article in French]
Service de chirurgie digestive, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy cedex, France. firstname.lastname@example.org
The current treatment for acute appendicitis is an appendectomy. Several studies have, however, assessed the efficacy of an antibiotic for treating acute appendicitis that is either uncomplicated or complicated by local peritonitis. A meta-analysis in 2007 that collected the results of 44 prospective studies showed that antibiotics were efficacious in 92.8% of cases of appendicitis complicated by local peritonitis, with percutaneous drainage of an abscess when necessary. No predictive factor for failure was identified. The failure of antibiotic treatment did not increase morbidity. Over time and on the whole, the recurrence rate was only 8.9%. The risk of cancer of the appendix (1.5%) nonetheless led to the recommendation of an interval appendectomy for adults. Four randomized controlled trials have compared antibiotic treatment with an appendectomy for the treatment of uncomplicated acute appendicitis. The efficacy of the antibiotic treatment ranged from 86 to 100% and the recurrence rate from 10.4 to 35%. These studies have had various methodological impediments; however, too few patients were included (40 and 80 patients), or only a clinical diagnosis was made before inclusion, or important protocol violations occurred, in particular for almost half the patient in the antibiotic therapy group in the 2009 study. These problems prevent us from relying on these authors’ findings. Antibiotics have a role in the initial treatment of acute appendicitis complicated by local peritonitis. In uncomplicated acute appendicitis, the methodological inadequacy of the currently available randomized trials makes it impossible to reach a definitive conclusion about the efficacy of antibiotics.
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