Several recent studies suggesting that appendicitis could be treated with antibiotics alone have generated serious buzz among clinicians and parents.
The antibiotics-only approach has been used in adults for several decades, but in children, it remains new, is still deemed experimental, and does not preclude disease recurrence down the road, say pediatric surgeons at Ann & Robert H. Lurie Children’s Hospital of Chicago.
Appendicitis is responsible for more than 300,000 surgeries a year in the United States. It occurs most commonly in children and teens ages 10-19. One in five pediatric surgeries is performed for appendicitis.
Experts have flagged several concerns with the medication-only approach. These include longer stays, possibility for disease recurrence, and side effects such as antibiotic-induced diarrhea. For these reasons, the decision to treat a child with antibiotics rather than surgery should not be made lightly, Lurie Children’s surgeons say. Clinicians and parents must carefully weigh such concerns against other factors, including a child’s overall health, the severity of symptoms, and the degree of appendix inflammation.
Lurie Children’s Hospital is part of a multi-center national trial to compare the long-term outcomes of children treated with antibiotics with those undergoing surgery. The findings will help answer some of the lingering questions surrounding antibiotic-only therapy for a condition that has been treated with surgery for more than a century, researchers say.
“No matter how straightforward, no operation is completely risk-free, so the notion of avoiding surgery is decidedly tantalizing,” says Julia Grabowski, MD, an attending physician at Lurie Children’s Division of Pediatric Surgery and assistant professor of surgery at Northwestern University Feinberg School of Medicine. “Antibiotics are a legitimate therapeutic choice in a small number of children with appendicitis, but it’s important to remember it’s surgery that remains the standard of care for most kids.”
Even if antibiotics quell the initial infection and a child gets better, appendicitis can recur, necessitating a surgery down the road, Lurie Children’s specialists say. In addition, any child with a history of antibiotic-treated appendicitis who later develops abdominal pain may require repeat visits to the emergency department and imaging tests to rule out disease recurrence.
Catherine Hunter, MD, an attending physician in the Division of Pediatric Surgery at Lurie Children’s and assistant professor of surgery at Northwestern University Feinberg School of Medicine, says, “As surgeons we should always consider non-surgical alternatives to clinical problems. While non-operative treatment may be appealing in the short run, we must bear in mind that not having surgery can create its own set of challenges down the road.”
STOPPING RECURRENCE
One of the most critical questions in the drugs-versus-surgery conundrum remains whether antibiotics provide a truly permanent solution, Hunter notes.
Most studies comparing treatment outcomes followed patients for a year or less, so it remains unclear whether those treated with antibiotics had a recurrence and required surgery past the one-year mark. A small study among Swedish children revealed that 62% of those treated with antibiotics did not need a surgery within a year of antibiotic treatment.
One of the largest clinical trials to date was a study conducted in Finland among more than 500 adult patients and published in The Journal of the American Medical Association in 2015. In that study, more than a quarter of patients treated with antibiotics ended up undergoing surgery within a year of treatment. Most of those who required surgery had the procedure within three months of initial diagnosis.
In addition, Hunter says, it remains uncertain precisely which patients might benefit the most from antibiotics and holding off surgery.
Another vexing concern is that even if a child gets better, any subsequent abdominal pain may signal recurrent appendicitis, Hunter and colleagues say. That possibility alone will result in repeat visits to the doctor, more imaging tests, and, in some cases, an eventual surgery. “Every time a child with history of antibiotic-treated appendicitis develops belly pain, the question of another episode will loom large,” Hunter says.
Appendicitis is a spectrum disorder ranging from simple to complicated, the latter of which can lead to a serious widespread infection of the entire abdomen. Disease severity is determined by a physical exam as well as blood and imaging tests.
If a child has been diagnosed with uncomplicated appendicitis, antibiotics might be a reasonable approach, but aren’t necessarily the first choice. The decision must be made on a case-by-case basis, depending on test results, the degree of organ inflammation, and the severity of symptoms, says Grabowski.
