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Original Investigation
May 2017

Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in ChildrenA Meta-analysis

Author Affiliations
  • 1Department of Gastrointestinal Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
  • 2Laboratory of Digestive Surgery, West China Hospital and State Key Laboratory of Biotherapy, Sichuan University, Chengdu, China
  • 3Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, China
JAMA Pediatr. 2017;171(5):426-434. doi:10.1001/jamapediatrics.2017.0057
Key Points

Question  Are antibiotics as initial treatment appropriate for uncomplicated acute appendicitis in pediatric patients?

Findings  In this meta-analysis of 5 studies (including 404 patients), antibiotic treatment was safe and effective in 152 of 168 pediatric patients (90.5%), but the risk for treatment failure increased significantly in patients with appendicolith.

Meaning  Antibiotic treatment can be used as primary treatment in pediatric patients presenting with acute uncomplicated appendicitis without appendicolith.

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.

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