In a randomised trial, two-thirds of antibiotic-treated children with appendicitis avoided appendectomy for at least one year.

In recent trials, researchers have explored antibiotic therapy for uncomplicated appendicitis as an alternative to appendectomy in adults, but large randomised trials in children have been lacking. In this multicentre noninferiority trial, 936 children (age range, 5 to 16 years) who presented with suspected unperforated appendicitis, with or without faecalith, were randomised to receive either antibiotic therapy (intravenous in hospital, followed by 10 days of oral therapy after discharge) or appendectomy. Inpatient antibiotic choice was left to physicians’ preferences. Outpatient antibiotic regimens were either amoxicillin-clavulanate or ciprofloxacin and metronidazole. Treatment failure was defined as a pathological finding of normal appendix or major complications for children in the appendectomy group, and need for appendectomy within one year in the antibiotic group.

Treatment failure occurred in 34% of children who received antibiotics and 7% of those who underwent appendectomy. The noninferiority margin of 20%, prespecified by the investigators, was not met. A perforated appendix was present in 6% of patients who underwent initial appendectomy; in the antibiotic group, 15% required appendectomy during initial hospitalisation, and one-third of those had perforations. No serious adverse outcomes or deaths occurred in either group. Antibiotic recipients had a slightly longer mean length of hospitalisation but a slightly faster return to school activities and sports compared with those who underwent appendectomy.

Comment: In this study, 66% of participants who received antibiotics avoided surgery for at least one year, without serious adverse events. Even though this outcome failed to meet the prespecified noninferiority margin, this rate is sufficient to discuss antibiotics with parents, if their preference is to avoid surgery.

Nolan J. Mischel, MD, Assistant Professor of Medicine, Texas Christian University, Burnett School of Medicine; Core Family Medicine Faculty, John Peter Smith Hospital, Fort Worth, USA.

St Peter SD, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial. Lancet 2025; 405: 233-240.

This summary is taken from the following Journal Watch titles: Infectious Diseases, Pediatrics and Adolescent Medicine.