Level 2: Mid-level evidence

Antibiotics may be an effective alternative to an appendectomy for patients with acute appendicitis, based on the results of a randomized trial conducted in six hospitals in Sweden (World J Surg. 2006;30:1033-1037). Men aged 18-50 years (N=252) planning to undergo appendectomy for acute appendicitis were randomized to surgery (open or laparoscopic) vs. antibiotics (cefotaxime [Claforan] 2 g IV every 12 hours plus tinidazole [Fasigyn] 0.8 g IV daily for two days, then ofloxacin [Floxin] 200 mg orally twice daily plus tinidazole 500 mg orally twice daily for 10 days). Additional inclusion criteria were C-reactive protein level >10 mg/L and no suspicion of perforated appendix. Imaging studies were not described as part of the diagnostic evaluation. Appendectomy was performed in the antibiotic group if symptoms did not resolve within 24 hours.

Among patients randomized to surgery, 97% had appendicitis; three patients had mesenteric adenitis and one patient had no pathology. Six patients (5%) had perforated appendix, and 14% had complications (mostly wound infections).

In patients randomized to antibiotics, 86% improved without surgery. A diagnosis of appendicitis was confirmed in 17 of 18 patients (94%) who had surgery; one patient had terminal ileitis. Seven patients (5%) had perforated appendix, and 14% had recurrent symptoms during one-year follow-up (including five patients with perforated appendix).

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Comparing patients assigned to antibiotics vs. those assigned to surgery, there were 12 cases (9.4%) vs. six cases (4.8%) of perforated appendix within one year (NNH 21 but not statistically significant). There were also no significant differences in mean hospital stay (3 vs. 2.6 days), mean sick leave (5.3 vs. 6 days), or mean time off work (8 vs. 10.1 days). This trial did not have adequate power to rule out a clinically significant difference in rates of perforated appendix. It is not clear that this trial is sufficient to change standard of care.