More than half of people treated with antibiotics for appendicitis experience no recurrence of the condition within 10 years, according to a new study published January 21 in JAMA. The findings, stemming from one of the first clinical trials to examine this approach, support recently updated guidelines that offer antibiotics as a viable alternative to surgical removal of the appendix.
Approximately 250,000 people in the United States are diagnosed with appendicitis annually, a condition characterized by inflammation of the appendix, often due to a blockage or infection. For over a century, the standard treatment has been appendectomy – surgical removal of the organ – driven by concerns about rupture and subsequent severe infection. However, over the past decade, clinical trials have demonstrated that appendicitis frequently resolves effectively with antibiotic therapy.
The landmark Appendicitis Acuta trial, initiated in 2009 in Finland, compared outcomes between 530 adults with appendicitis who received either antibiotics or appendectomy. Participants were carefully selected to include only those with uncomplicated appendicitis – meaning the appendix was inflamed but had not ruptured or developed infected pockets.
After a decade of follow-up, researchers were able to contact 224 of the original 257 patients treated with antibiotics and 219 of the 273 who underwent appendectomy. Health records were consulted to determine outcomes for those who could not be reached. A total of 112 patients initially treated with antibiotics ultimately required an appendectomy. Of these, 70 underwent the procedure within the first year, 30 between two and five years, and 12 between six and 10 years after initial treatment, according to the study.
“The study protocol required an appendectomy for anyone with suspected recurrence, so it’s possible some of those additional surgeries were not needed,” explained principal investigator Paulina Salminen, a surgeon at Turku University Hospital in Finland. Despite this, the data suggest that antibiotics remain a safe and effective long-term option for many patients.
Two patients in the antibiotic group experienced new complications between the five- and 10-year marks, both related to subsequent appendectomy. Two patients in the appendectomy group reported new scar numbness or pain. “You don’t have to operate,” Salminen stated. “The majority can be treated without appendectomy, and We see safe for the patients” in the long-term.
Beyond avoiding surgery, antibiotic treatment offers potential cost savings through more efficient use of hospital resources and reduced patient sick time, Salminen noted. She estimates that 60 to 70 percent of individuals presenting with acute appendicitis have the uncomplicated form, making them potentially eligible for antibiotic therapy.
These findings reinforce the growing acceptance of antibiotics as a reasonable treatment option, according to David Flum, a surgeon at the University of Washington in Seattle. Flum is also an investigator on the Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial, a U.S.-based study modeled after the Finnish research.
“The latest results are just a little bit more reassurance for folks who want to go the antibiotic route that it’s not inevitable they’re going to have their appendix out,” Flum said. “That’s important.” Preliminary data from the CODA trial show that approximately 40 percent of participants initially treated with antibiotics required an appendectomy within one year, increasing to 49 percent by four years.
The accumulating evidence underscores the importance of shared decision-making between patients and physicians when determining the optimal treatment approach. “There’s no one right answer here,” Flum emphasized.
To facilitate informed discussions, Flum developed a web-based decision-making tool to help patients understand their treatment options. Initial data showed that 55 percent of the 8,243 patients who used the tool were initially undecided between antibiotics and surgery. After using the tool, this indecision decreased to 49 percent. An analysis of 356 participants who engaged with the decision-making process revealed that over 90 percent felt confident in their final choice.
On January 28, Flum and Salminen, as part of a collaborative committee, announced updated guidelines for treating appendicitis, published in JAMA Surgery. While previous versions acknowledged antibiotics as a possible treatment, the updated guidelines now specifically recommend incorporating shared decision-making – such as utilizing tools like Flum’s – into the development of a personalized treatment plan.
Salminen believes that even this shift represents a step, but not the final one. She is currently leading a clinical trial investigating whether appendicitis can resolve without any intervention at all, comparing antibiotics to a placebo. “You have to be able to think outside the box,” she said. “‘We’ve always done this’ is not a good rationale for doing something.”
