Treatment with antibiotics alone was safe and allowed two-thirds of patients to avoid appendectomy within one year.

Emerging evidence suggests that antibiotic treatment alone is a viable alternative to surgery in some patients with appendicitis (NEJM JW Gen Med Jan 1 2021). In this meta­ analysis, researchers used individual patient data from six randomised trials to compare antibiotics with appendectomy in 2100 adults with imaging-confirmed acute appendicitis.

Results at one year included the following:

• about one­-third (34%) of patients randomised to antibiotics eventually underwent surgery
• incidence of complications was not significantly different between the antibiotic and appendectomy groups (5% and 8%, respectively)
• among patients with appendicoliths at preintervention imaging, complications were significantly more common in those randomised to antibiotics (15%) than to appendectomy (6%)
• in the antibiotics group, more patients with appendicoliths required appendectomy (49%) than patients without appendicoliths (31%).

Comment: This meta-­analysis further establishes antibiotic treatment as a safe alternative to appendectomy for adults with imaging-­confirmed acute appendicitis. However, elevated risks for complications and subsequent appendec­ tomies in patients with appendicoliths should be considered in decision making. It is unclear whether a nonsurgical approach will become popular in the USA, but clinicians and patients now have more data to inform their decisions.

Paul S. Mueller, MD, MPH, FACP, The Dr. Lowell Henry Lebermann Endowed Chair in Internal Medicine and Professor of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, USA.

Scheijmans JCG, et al. Antibiotic treatment versus appendicectomy for acute appendicitis in adults: an individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2025; 10: 222-233.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine.