Among children with uncomplicated appendicitis, initial antibiotic intervention was associated with significantly fewer disability days at 1 year when compared with laparoscopic appendectomy; however, nonoperative management failed to achieve statistical significance for success, according to a study published in JAMA.
Between May 1 2015 and October 31, 2018, a total of 1068 patients at 10 children’s hospitals participated in the study; children and their families chose between nonoperative management with antibiotics alone and surgery. Participants were included based on the following criteria: imaging-confirmed uncomplicated appendicitis of an appendix with a diameter ≤1.1 cm with no abscess, fecalith, or phlegmon, and a white blood cell count of 5000/μL to 18,000/μL; and abdominal pain for <48 hours prior to starting antibiotics.
Researchers hypothesized that nonoperative management would have a ≥75% success rate and would be associated with 5 fewer disability days compared with children who had initial surgery. Nonoperative management was deemed a failure if a patient did not show clinical improvement after 24 hours of intravenous (IV) antibiotics, or exhibited clinical deterioration.
Patients in the operative group underwent a laparoscopic appendectomy within 12 hours of admission; IV antibiotics (piperacillin-tazobactam or ciprofloxacin and metronidazole if penicillin allergic) were administered upon arrival, and antibiotics were discontinued postoperatively. Patients were discharged home with standardized instructions on returning to daily activities upon tolerance of a regular diet.
Nonoperative patients were managed for a minimum of 24 hours with intravenous (IV) antibiotics (piperacillin-tazobactam or ciprofloxacin and metronidazole if allergic to penicillin). Children were allowed to eat only after a minimum of 12 hours and only when they demonstrated a decrease in pain or tenderness. Once patients were able to tolerate a regular diet (defined as consuming ≥50% of what they would eat at home), they were switched to oral amoxicillin-clavulanate or ciprofloxacin and metronidazole if allergic to penicillin. Patients were discharged home with instructions for resuming normal activities and an oral antibiotic prescription to complete a total course of 7 days.
Among the 1068 patients in the study, 370 (35%) of patients chose nonoperative management and 698 (65%) chose surgery. Patients who chose nonoperative management were more likely to be non-White, have caregivers with a bachelor’s degree (29.8% vs 23.5%), and have undergone an ultrasound (79.7% vs 74.5%) but less likely to have undergone a computed tomography scan (27.6% vs 32.4%) compared with operative candidates.
At 1-year follow up, the success rate of nonoperative management was 67.1%, and the number of disability days were significantly lower in the nonoperative management group compared with the surgery group (adjusted, 6.6 vs 10.9 days; mean difference, -4.3 days). During the initial hospitalization, the success rate for nonoperative management was 85.4%; 53 patients who chose medical management had to undergo an appendectomy. Of these cases, 16 were due to caregiver election to convert to surgery, 16 were due to clinical worsening, 16 patients did not improve, and 6 did not meet discharge criteria within 48 hours.
At 30 days, nonoperative management was linked to significantly fewer disability days for patients (adjusted, 3.3 vs 6.5 days) and caregivers (adjusted, 2.4 vs 3.1 days). The adjusted health-related quality of life scores reported by patients and caregivers were significantly higher in the nonoperative group at 30 days than in the surgery group (patient report, 89.0 vs 86.3; parent-proxy report, 89.5 vs 86.3).
“This study also provides generalizable estimates of the expected postoperative outcomes associated with laparoscopic appendectomy for uncomplicated appendicitis,” wrote the researchers. These included a 6.9% rate of emergency department visits, 2.9% rate of readmissions, 1.1% rate of postoperative infections, and 0.6% rate of reoperation.
“With increasing experience with nonoperative management within pediatric surgery, outpatient nonoperative management protocols may be able to be initiated and studied in the near future.”
Minneci PC, Hade EM, Lawrence AE, et al. Association of nonoperative management using antibiotic therapy vs laparoscopic appendectomy with treatment success and disability days in children with uncomplicated appendicitis. JAMA. Published online July 27, 2020.