To the Editor We found the 2018 “Update on Pediatric Medical Overuse: A Review” by Coon et al1 to be a well-meaning attempt at a worthwhile goal. However, we are compelled to comment on the mischaracterization of nonoperative, antibiotic treatment of uncomplicated appendicitis. While many of the topics addressed in the review highlight opportunities for resource-effective management in treatment situations for which there is documented clinical equipoise, this is not the case as suggested for acute appendicitis. Citing a meta-analysis in JAMA Pediatrics,2 Coon et al1 highlight a claim of 91% success rate of nonoperative therapy. In fact, this figure only represents the first 48 hours from diagnosis. Rather, we suggest that it is the 27% failure rate during the first year of follow-up that is the most relevant statistic that clinicians and families should discuss. This is consistent across most studies comprising both adult and pediatric occurrences. Presence of appendicolith, not mentioned by Coon et al,1 is a known contraindication for nonoperative therapy owing to a prohibitively high failure rate.3 Furthermore, long-term follow-up in regard to lifelong recurrence risk and pathologic implications of nonoperative management of appendicitis has not yet been fully studied.
Goldstein SD, Raval MV. Medical Overuse and Appendicitis Treatment. JAMA Pediatr. Published online July 22, 2019173(9):891–892. doi:10.1001/jamapediatrics.2019.2394
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