The last decade or so featured a rather notable increase in palatability for the conservative management of appendicitis. Why undergo surgery for a condition antibiotics can cure? You wouldn’t take out your bladder for a urinary tract infection, would you?
This latest randomized trial adds to the evidence surrounding the “antibiotics first” strategy for appendicitis by expanding it to children. The failure rates at one year for the “antibiotics first” strategy in adults have been established at roughly 30%, as confirmed in another recent individual patient meta-analysis. At long-term follow-up, the failure rate approaches 50%.
In this trial of nearly 1,000 children across Canada, the USA, Finland, Sweden, and Singapore, virtually the same failure rate was seen, at 34%. Approximately half of the failures occurred at the index hospitalization, whereas the remainder occurred over the one year of follow-up. Conversely, the “negative appendectomy rate”, the measure of failure for those in the surgery arm, was 7%. Adverse events were low and similar across each group.
It is fairly clear the “antibiotics first” strategy, when it works, is superior. These children spent less time in the hospital, were back to normal activity sooner, and required less analgesia. I would suspect, overall, it is also less expensive – whether those costs are born by individual families, or by the health systems in total. However, the observed failure rate – and extrapolating to higher, longer term failures, as with adults – remains a vexing issue. The authors probably summed it up most accurately themselves
“… we suspect that this difference will continue to be interpreted from opposite viewpoints. Those most interested in avoiding an operation will see these data as providing hope, whereas those most interested in avoiding initial treatment failure or recurrence will see the failure rate as unacceptably high.”
Importantly, though, even if these data refuse to give us a solid answer, these do finally give us robust data in children to assist in those shared decision-making conversations.
“Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial”
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02420-6/fulltext
I don’t have access to the full text of the article. A discussion of the relative benefits of the approaches is probably discussed at more length than would fit in one of your articles. The part that seems to me to be odd is the idea that giving antibiotics in the hope of avoiding surgery is a failure if the surgery is eventually performed.
If I start a patient on oxygen by nasal cannula for any respiratory condition, I don’t consider it a failure of the oxygen delivery device, if I have to increase the rate of oxygen flow, or have to progress to more invasive oxygen delivery devices (CPAP, intubation, …). I consider the reasonable progression of intervention to be most likely to produce a patient oriented outcome. Rushing to intubate, in the absence of at least a trial of less invasive oxygen delivery does not seem to be appropriate for most patients.
If I were to be able to avoid intubation by focusing on improving everything non-invasive – posture, clearing the airway, increasing the amount of oxygen being delivered, providing medications to open the airway, . . . – for only 2/3 of patients, I would not consider that to be a treatment failure of the less invasive approach. I would actually consider the more aggressive approach, which was the “standard” approach when I started, to be a failure to provide the care the patient needed. Some of this comes from experience, but the research seems as if the initial care would be provided in pediatric emergency departments, or following transfer to pediatric emergency departments. This would seem to help identify if there is some sort of assessment that could be used to determine which patients are most likely to be among the 2/3 of patients who have the best outcome without surgery and which are most likely to be among the 1/3 of patients who only seem to be able to delay surgery – and sometimes not delay the surgery for long?
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That’s probably a fair perspective to use – I don’t think the authors were pro- or anti-antibiotics, specifically, and their conclusion is simply: look, more data. I think it would be absolutely appropriate to admit someone for conservative management using antibiotics as first-line – and then about 15% will fail and go to surgery – but the other 85% will get better. It’s really the remaining 15% of those who ultimately require surgery that ought to be considered the “failure rate”.
It might be the next necessary step is really: can we find a way to predict which patients will fail within a year?