Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis

Abstract

Importance: Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial.

Objective: To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients.

Data sources: The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial.

Study selection: Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days.

Data extraction and synthesis: Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated.

Main outcomes and measures: The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection.

Results: A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%).

Conclusions and relevance: This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.

Figure 1.. Forest Plot Showing Risk Ratio (RR) in Failure Rate in the Antibiotic vs Appendectomy Groups

Risk ratios were calculated using the Mantel-Haenszel method to combine summary statistics, and data were pooled using a fixed-effects model. ^aEvents were defined as initial failure of treatment. ^bTwo initial treatment failures and 2 recurrences of appendicitis occurred within 30 days. ^cOne initial treatment failure and 4 recurrences of appendicitis occurred within 30 days.

Figure 2.. Subgroup Forest Plot Showing Risk Ratio (RR) in Failure Rate in Patients With Appendicolith in the Antibiotic Therapy vs Appendectomy Groups

Risk ratios were calculated using the Mantel-Haenszel method to combine summary statistics, and data were pooled using a fixed-effects model. ^aEvents were defined as failure rate at 1-year follow-up. ^bNo data were available in the appendectomy group. ^cPatients with incomplete data were excluded from the analysis.

Figure 3.. Forest Plot Showing Mean Difference in Total Cost in Antibiotic Therapy vs Appendectomy Groups

Mean differences were calculated using the inverse variance method with fixed effects.