Antibiotics Over Surgery for Appendicitis? Experts Say Proceed with Caution

-Lurie Children’s surgeons offer tips for parents on making the right call

Newswise — Several recent studies suggesting that appendicitis — the leading cause of emergency abdominal surgery in children — could be treated with antibiotics alone have generated serious buzz among clinicians and parents alike.
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.
Experts have flagged several concerns with the medication-only approach they say parents ought to be aware of. These include longer hospital stays, possibility for disease recurrence and side effects such as antibiotic-induced diarrhea. This is why, Lurie Children’s experts say, the decision to treat a child with antibiotics rather than surgery should not be made lightly. 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 is part of a multi-center national trial, now under way, to compare the long-term outcomes of children treated with antibiotics with those undergoing surgery. The findings, researchers say, 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.

“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 surgery that remains the standard of care for most kids.”

Even if antibiotics quell the initial infection and a child gets better, Lurie Children’s specialists say, appendicitis can recur, necessitating a surgery down the road. In addition, any child with a history of antibiotic-treated appendicitis who later develops abdominal pain may require repeat visits to the emergency room and imaging tests to rule out disease recurrence.

“As surgeons we should always consider non-surgical alternatives to clinical problems,” says 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. “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.”

Appendicitis, an infection of a small pouch known as the appendix at the end of the large intestine, is responsible for more than 300,000 surgeries a year in the United States. It occurs most commonly in children and teens between the ages of 10 and 19. One in five pediatric surgeries is performed for appendicitis. Most cases are treated by surgically removing the inflamed organ, often done through minimally invasive techniques that allow kids to go home on the day of the procedure or a day or two following operation. Patients also receive preventive antibiotics before surgery to reduce the risk of widespread abdominal infection.

Antibiotics don’t preclude disease recurrenceOne of the most critical questions in the drugs-versus-surgery conundrum, Dr. Hunter notes, remains whether antibiotics provide a truly a permanent solution. 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 percent of those treated with antibiotics did not need a surgery within a year of antibiotic treatment. In one of the largest clinical trials to date — a study conducted in Finland among more than 500 adult patients and published in The Journal of the American Medical Association in 2015 — more than a quarter of patients treated with antibiotics ended up undergoing surgery within a year of treatment. The majority of those who required surgery had the procedure within three months of initial diagnosis. In addition, Dr. Hunter says, it remains uncertain precisely which patients might benefit the most from antibiotics and are better off holding off on surgery.
The ghost of appendicitis past…Another vexing concern, Dr. Hunter and colleagues say, is that even if a child gets better, any subsequent abdominal pain may signal recurrent appendicitis. 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,” Dr. Hunter says.

Antibiotics may be the right call in some casesAppendicitis 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 and blood and imaging tests. If your child has been diagnosed with uncomplicated appendicitis, antibiotics may be a reasonable approach, but are not necessarily the first choice. The decision, says Dr. Grabowski, must be made on a case-by-case basis, depending on test results, the degree of organ inflammation and the severity of symptoms.

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