A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues? Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible RETRACTED ARTICLE: Conservative Management of Acute Appendicitis Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial) Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children. Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. Appendiceal mass: conservative therapy followed by interval laparoscopic appendectomy. Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis Non‐operative Management for Uncomplicated Appendicitis: An Option to Consider Retraction Note to: Conservative Management of Acute Appendicitis Expanding the inclusion criteria for nonoperative management of uncomplicated appendicitis: Outcomes and cost. Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline Discharge planning for children with perforated appendicitis. A role for conservative antibiotic treatment in early appendicitis in children. The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. NICE guidance on reducing the risk of venous thromboembolism in patients admitted to hospital Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Can oral metronidazole substitute parenteral drug therapy in acute appendicitis? A new policy in the management of simple or complicated appendicitis with localized peritonitis: a randomized controlled clinical trial. Antibiotics‐First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management Ultrasound-based decision making in the treatment of acute appendicitis in children. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis.
Introduction : The management approach for acute appendicitis has been challenged in recent years , with numerous r and omized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment , with lower complication rates . Methods : A national survey of all consultant general surgeons evaluating their practice s was performed . Reasons for changed practice s , choice of antibiotics and follow-up investigations were evaluated . In addition , the role of interval appendicectomy and conservative management in the pediatric population was also assessed . Results : The response rate for this survey was 74.7 % ( n = 74/99 ) . Over one-fifth ( n = 17 , 22.9 % ) routinely treat acute appendicitis conservatively , while another 14.8 % ( n = 11 ) consider this approach in selected cases . Main reasons for modified practice s included the presence of inflammatory phlegmon ( 75 % ) , delayed presentation ( 64 % ) , and recent evidence -based medicine developments ( 46 % ) . Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management ( 53 % ) . Alternatively , combinations of antibiotics were also utilized . One-third felt interval appendicectomy was warranted , while one-fifth supported conservative management in the paediatric setting . The overwhelming majority ( > 95 % ) advocate follow-up colonoscopy ± computed tomography in any patient aged > 40 years managed conservatively . Conclusion : Considerable variation in management of uncomplicated appendicitis  remains in Irel and despite growing evidence suggesting that the non-operative approach is safe . Reasons for adopting a conservative management practice have been identified and reflect the exp and ing literature on this subject Purpose Appendectomy versus conservative antibiotic treatment ( CAT ) for children with acute uncomplicated appendicitis ( AUA ) remains unresolved , with concerns regarding the practicality of CAT . We analyzed our center ’s experience with CAT for AUA , using a protocol with strict inclusion , exclusion and treatment criteria . Methods Non-r and omized , prospect i ve cohort study included all children admitted betwee 2014 and 2016 , with clinical and laboratory tests suspicious for AUA . Data collected included clinical signs and symptoms ; laboratory , ultrasound and pathology results . Follow-up was conducted through clinic visits , telephone conversations and national registry analysis . Results Included in CAT : 362 children , 19 underwent appendectomy within 1–2 days . Overall , 75 were readmitted for recurrent acute appendicitis during 22 months ( 6–43 ) follow-up . Thirty were treated successfully with antibiotics a second time . The remaining 45 had appendectomy . Overall , 86.8 % underwent CAT with no surgery . Histology of all recurrent AUA revealed no perforations . Conclusion We confirm the feasibility of conservative management of AUA in children . A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile . CAT does not compete with surgery or render appendectomy unnecessary . It is a safe alternative to surgery in selected cases Background The acute appendicitis is the most common abdominal emergency , and the primary treatment has been appendicectomy . Antibiotics are started preoperatively and continued postoperatively as needed . Methods This prospect i ve study was carried out at Sher-i-Kashmir Institute of Medical Sciences , Soura , Srinagar , Kashmir , India to determine the role of antibiotics as the only treatment in acute appendicitis and the analgesic consumption needed . Total of 80 patients were included in the study with a duration of abdominal pain less than 72 h. Out of 80 patients , 40 patients received antibiotics intravenously for 2 days followed by oral treatment for 7 days , while another 40 patients considered as controls were r and omized to surgery . Results Patients managed conservatively were discharged within 3 days except for two— patients who required surgery after 12 and 24 h , respectively , because of peritonitis due to perforated appendicitis . Four patients were readmitted within 1 year as a result of recurrent appendicitis and had to undergo surgery when appendicitis was confirmed . The diagnostic accuracy within the operated group was 90 % . Two patients had perforated appendicitis at operation . Conclusion Our conclusion is that antibiotic treatment in the patients with acute appendicitis is quite effective , and these patients may not need surgery . The patients managed conservatively with antibiotics alone experience less pain and require less analgesia but have high recurrent rate IMPORTANCE Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe , but overall effectiveness is determined by combining medical outcomes with the patient 's and family 's perspective , goals , and expectations . OBJECTIVE To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1 , 2012 , through March 6 , 2013 . Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy . INTERVENTIONS Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and , on demonstrating improvement of symptoms , completion of 10 days of treatment with oral antibiotics . MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year success rate of nonoperative management . Successful nonoperative management was defined as not undergoing an appendectomy . Secondary outcomes included comparisons of the rates of complicated appendicitis , disability days , and health care costs between nonoperative management and surgery . RESULTS A total of 102 patients were enrolled ; 65 patients /families chose appendectomy ( median age , 12 years ; interquartile range [ IQR ] , 9 - 13 years ; 45 male [ 69.2 % ] ) and 37 patients /families chose nonoperative management ( median age , 11 years ; IQR , 10 - 14 years ; 24 male [ 64.9 % ] ) . Baseline characteristics were similar between the groups . The success rate of nonoperative management was 89.2 % ( 95 % CI , 74.6%-97.0 % ) at 30 days ( 33 of 37 children ) and 75.7 % ( 95 % CI , 58.9%-88.2 % ) at 1 year ( 28 of 37 children ) . The incidence of complicated appendicitis was 2.7 % in the nonoperative group ( 1 of 37 children ) and 12.3 % in the surgery group ( 8 of 65 children ) ( P = .15 ) . After 1 year , children managed nonoperatively compared with the surgery group had fewer disability days ( median [ IQR ] , 8 [ 5 - 18 ] vs 21 [ 15 - 25 ] days , respectively ; P < .001 ) and lower appendicitis-related health care costs ( median [ IQR ] , $ 4219 [ $ 2514-$7795 ] vs $ 5029 [ $ 4596-$5482 ] , respectively ; P = .01 ) . CONCLUSIONS AND RELEVANCE When chosen by the family , nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis , incurring less morbidity and lower costs than surgery . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01718275 Background Although the st and ard treatment of acute appendicitis ( AA ) consists of an early appendectomy , there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA . However , the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial . Methods / design The APPAC trial is a r and omized prospect i ve controlled , open label , non-inferiority multicenter trial design ed to compare antibiotic therapy ( ertapenem ) with emergency appendectomy in the treatment of uncomplicated AA . The primary endpoint of the study is the success of the r and omized treatment . In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year ( treatment efficacy ) . Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100 % . Secondary endpoints are post-intervention complications , overall morbidity and mortality , the length of hospital stay and sick leave , treatment costs and pain scores ( VAS , visual analoque scale ) . A maximum of 610 adult patients ( aged 18–60 years ) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and r and omized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem ( 1 g per day ) for three days continued by oral levofloxacin ( 500 mg per day ) plus metronidazole ( 1.5 g per day ) for seven days . Follow-up by a telephone interview will be at 1 week , 2 months and 1 , 3 , 5 and 10 years ; the primary and secondary endpoints of the trial will be evaluated at each time point . Discussion The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75–85 % of patients with uncomplicated AA can be treated with effective antibiotic  therapy avoiding unnecessary appendectomies and the related operative morbidity , also result ing in major cost savings . Trial registration Clinical BACKGROUND For decades , urgent operation has been considered the only appropriate management of acute appendicitis in children . The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children . STUDY DESIGN A prospect i ve nonr and omized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy  was performed . The primary result was 30-day success rate of nonoperative management . Secondary outcomes included comparisons of disability days , missed school days , hospital length of stay , and measures of quality of life and health care satisfaction . RESULTS Seventy-seven patients were enrolled during October 2012 to October 2013 ; 30 chose nonoperative management and 47 chose surgery . There were no significant differences in demographic or clinical characteristics . The immediate and 30-day success rates of nonoperative management were 93 % ( 28 of 30 ) and 90 % ( 27 of 30 ) . There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed . Compared with the surgery group , the nonoperative group had fewer disability days ( 3 vs 17 days ; p < 0.0001 ) , returned to school more quickly ( 3 vs 5 days ; p = 0.008 ) , and exhibited higher quality of life scores in both the child ( 93 vs 88 ; p = 0.01 ) and the parent ( 96 vs 90 ; p = 0.03 ) , but incurred a longer length of stay ( 38 vs 20 hours ; p < 0.0001 ) . CONCLUSIONS Nonoperative management of uncomplicated acute appendicitis in children is feasible , with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores . Additional follow-up will allow for determination of longer-term success rate , safety , and cost effectiveness Uncomplicated appendicitis may resolve spontaneously or require treatment with antibiotics or appendicectomy . The aim of this r and omized trial was to compare the outcome of a non‐antibiotic management strategy with that of antibiotic therapy in uncomplicated appendicitis This guidance provides a data -supported approach to risk stratification , diagnosis , and management of patients with cirrhosis and portal hypertension ( PH ) . A guidance document is different from a guideline . Guidelines are developed by a multidisciplinary panel of experts who rate the quality ( level ) of the evidence and the strength of each recommendation using the Grading of Recommendations Assessment , Development , and Evaluation system . A guidance document is developed by a panel of experts in the topic , and guidance statements , not recommendations , are put forward to help clinicians underst and and implement the most recent evidence . This guidance focuses on PH , varices , and variceal hemorrhage ( VH ) , and statements are based on the following : ( 1 ) review of the recent literature using PubMed , giving more weight to large , well- design ed , prospect i ve trials and well-performed meta-analyses ; ( 2 ) several consensus conferences among experts ; and ( 3 ) the authors ’ years of experience caring for patients with cirrhosis and varices . Management of ascites and encephalopathy is addressed in other documents IMPORTANCE An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis . OBJECTIVE To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography ( CT ) . DESIGN , SETTING , AND PARTICIPANTS The Appendicitis Acuta ( APPAC ) multicenter , open-label , noninferiority r and omized clinical trial was conducted from November 2009 until June 2012 in Finl and . The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan . Patients were r and omly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period . INTERVENTIONS Patients r and omized to antibiotic therapy received intravenous ertapenem ( 1 g/d ) for 3 days followed by 7 days of oral levofloxacin ( 500 mg once daily ) and metronidazole ( 500 mg 3 times per day ) . Patients r and omized to the surgical treatment group were assigned to undergo st and ard open appendectomy . MAIN OUTCOMES AND MEASURES The primary end point for the surgical intervention was the successful completion of an appendectomy . The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period . RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group . Of 273 patients in the surgical group , all but 1 underwent successful appendectomy , result ing in a success rate of 99.6 % ( 95 % CI , 98.0 % to 100.0 % ) . In the antibiotic group , 70 patients ( 27.3 % ; 95 % CI , 22.0 % to 33.2 % ) underwent appendectomy within 1 year of initial presentation for appendicitis . Of the 256 patients available for follow-up in the antibiotic group , 186 ( 72.7 % ; 95 % CI , 66.8 % to 78.0 % ) did not require surgery . The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0 % ( 95 % CI , -31.6 % to ∞ ) ( P = .89 ) . Given the prespecified noninferiority margin of 24 % , we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery . Of the 70 patients r and omized to antibiotic treatment who subsequently underwent appendectomy , 58 ( 82.9 % ; 95 % CI , 72.0 % to 90.8 % ) had uncomplicated appendicitis , 7 ( 10.0 % ; 95 % CI , 4.1 % to 19.5 % ) had complicated acute appendicitis , and 5 ( 7.1 % ; 95 % CI , 2.4 % to 15.9 % ) did not have appendicitis but received appendectomy for suspected recurrence . There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients r and omized to antibiotic treatment . CONCLUSIONS AND RELEVANCE Among patients with CT-proven , uncomplicated appendicitis , antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy . Most patients r and omized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period , and those who required appendectomy did not experience significant complications . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01022567 BACKGROUND Current therapy of patients with appendiceal abscess or phlegmon is in evolution . Controversial areas include initial conservative therapy , drainage of periappendiceal abscesses , and the role of interval appendectomy . OBJECTIVE To evaluate the safety and efficacy of conservative therapy and of interval laparoscopic appendectomy ( ILA ) . PATIENTS AND METHODS Patients with signs and symptoms of acute appendicitis and a palpable right lower quadrant mass were included . Abscess/phlegmon was documented with ultrasound or computerized tomography . After initial therapy with antibiotics , patients were discharged to home . ILA was performed 6 to 12 weeks later . RESULTS Twelve patients were included . Four patients had phlegmonous appendicitis and eight had an abscess , but only four had percutaneous drainage . All patients improved without surgical exploration and were subjected to ILA . ILA was successful in 11 of 12 patients ; a median hospital postoperative stay of 1 day was required , and no perioperative morbidity was encountered . All patients returned to routine activities within 2 weeks of surgery . CONCLUSIONS 1 ) Initial conservative management of patients with appendiceal abscess/phlegmon is prudent , safe , and effective . 2 ) Interval laparoscopic appendectomy can be performed safely and effectively BACKGROUND In 2012 , a protocol for routine  outpatient laparoscopic appendectomy for uncomplicated appendicitis was published reflecting high success , low morbidity , and significant cost savings . Despite this , national data reflect that the majority of laparoscopic appendectomies are performed with overnight admission . This study up date s our experience with outpatient appendectomy  since our initial report , confirming the efficacy of this approach . METHODS In July 2010 , a prospect i ve protocol for outpatient  laparoscopic appendectomy  was adopted at our institution . Patients were dismissed from the postanesthesia recovery room or day surgery if they met predefined criteria for dismissal . Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management . An institutional review board – approved retrospective review of patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2012 was performed to analyze success of outpatient management , postoperative morbidity and mortality , as well as readmission rates . RESULTS Three hundred forty-five patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame . There were 166 men and 179 women , with a mean age of 35 years . Three hundred five patients were managed as out patients , with a success rate of 88 % . Forty patients ( 12 % ) were admitted for preexisting comorbidities ( 15 patients ) , postoperative morbidity ( 6 patients ) , or lack of transportation or home support ( 19 patients ) . Twenty-three patients ( 6.6 % ) experienced postoperative morbidity . There were no mortalities . Four patients ( 1 % ) were readmitted for transient fever , nausea/vomiting , partial small bowel obstruction , and deep venous thrombosis . CONCLUSION Outpatient laparoscopic appendectomy can be performed with a high rate of success , a low morbidity , and a low readmission rate . This study reaffirms our original pilot study and should serve as the basis for a change in the st and ard of care for appendicitis . LEVEL OF EVIDENCE Therapeutic study , level Abstract Aim The main goal of our study was to assess a 7 days long course of antibiotics for acute uncomplicated appendicitis . Material s and Methods From March 2014 to November 2015 , all patients diagnosed with acute appendicitis have been considered to be treated by only antibiotics .  Inclusion criteria included clinical ( tenderness ) , biological ( C‐reactive protein [ CRP ] < 50 ) , and radiological features ( diameter > 6 mm ) . All patients were treated with intravenous amoxicillin and clavulanic acid ( 100 mg/kg/day ) for 2 days ( six doses ) . At the end of the treatment , clinical and para clinical examinations included blood sample s at day 7 and ultrasound ( US ) scan at 3 months . Results A total of 166 patients were treated and followed up prospect ively during the study period . Mean age at diagnosis was 10.8 ± 0.6 years . All children , but four were discharged with a clinical improvement after 48 hours and six intravenous antibiotics injection according to our protocol . Four children required surgery during the initial hospitalization period . Initial ultrasound scan showed a mean diameter of 7.85 ± 1.6 mm , with inflamed fat in 124 patients ( 74.7 % ) . At Day 7 , the diameter was 5.2 ± 1.6 mm ( p < 0.0001 ) . During a median follow‐up of 18.8 months ( 3.5‐18 ) , 22 patients ( 13.25 % ) had to be managed for a novel episode of acute appendicitis after a median period of 138 days ( 13‐270 ) . None had to be managed for a complicated appendicitis . Conclusion Non‐operative treatment ( NOT ) is a safe alternative for the management of uncomplicated acute appendicitis in children . Further study should be conducted to determine relapse risk factors The editors of the Journal of Gastrointestinal Surgery as well as the SSAT Board of Directors have retracted the article Malik , A.A. & Bari , S.U. Conservative management of  acute appendicitis . J Gastrointest . Surg 13 , 966–970 ( 2009 ) since significant portions of the article were published earlier in the following articles : Eriksson , S. & Granstrom , L. R and omized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis . Br J Surg 82 , 166–169 ( 1995 ) . Horton , M.D. , Counter , S.F. , Florence , M.G. & Hart , M.J. A prospect i ve trial of computed tomography and ultrasonography for diagnosing  appendicitis in the atypical patient . Am J Surg 179 , 379–381 ( 2000 ) BACKGROUND Carefully selected children with early appendicitis may be managed nonoperatively . However , it is unknown whether nonoperative management ( NOM ) is applicable to all patients with uncomplicated appendicitis . The purpose of this study was to evaluate the outcomes of NOM of uncomplicated appendicitis with exp and ed inclusion criteria . METHODS A prospect i ve , nonr and omized patient-preference study comparing NOM versus laparoscopic appendectomy ( LA ) was performed in children with radiographic/ clinical evidence of uncomplicated appendicitis . RESULTS Demographics , laboratory values , and clinical presentation were similar between the  NOM ( n=51 ) and LA ( n=32 ) groups . Initial failure rate was 31 % . The outcomes were similar between groups , except that NOM had fewer days of pain medication . Patients who failed NOM had a longer duration of symptoms prior to admission . Patients with appendicolith had a failure rate of 50 % compared to 24 % without appendicolith . The recurrence rate was 26 % . Overall , 51 % avoided appendectomy . Costs were similar between NOM and LA . CONCLUSIONS When exp and ing the inclusion criteria for children with presumed uncomplicated appendicitis , NOM was associated with high failure and recurrence rates . These high rates may be because of the inclusion of patients with complicated appendicitis and patients with an appendicolith . Even in this setting of less-restrictive exclusion criteria , NOM remained cost neutral . LEVEL OF EVIDENCE LEVEL II ( Treatment Study : Prospect i ve Comparative Study ) Abstract Chest X-rays ( CXR ) , antibiotics and inhaled/nebulized therapy are overused in bronchiolitis , despite evidence -based guidelines suggesting supportive management only . This study investigates the effect of the implementation of the NICE bronchiolitis guideline in a secondary paediatric unit in Engl and . We present a quality improvement project with a completed audit cycle ( winter 2014–2015 and 2015–2016 ) pre- and post-implementation of the NICE bronchiolitis guideline . The educational intervention included sessions for raising awareness of appropriate and inappropriate management of bronchiolitis for both clinicians and nursing staff . As a result , the number of chest radiographs reduced fivefold ( from 20 to 4 % of patients , absolute reduction 16 % ) ,  antibiotics  reduced more than threefold ( from 22 to 6 % of patients , absolute reduction 16 % ) and inhaled/nebulised treatment up to twofold ( from 30 to 16 % , absolute reduction 14 % ) . Overall NICE guideline compliance rose from 28 to 63 % . Conclusion : Implementation of the NICE bronchiolitis guideline supported by a simple educational intervention can effectively reduce the number of inappropriate chest radiographs and antibiotic prescribing in bronchiolitis , and enhance compliance with the NICE guideline .What is Known:• Bronchiolitis management in paediatric units in the UK is variable , with poor evidence for existing guidance . Best available evidence was compiled into the NICE guideline , aim ing to st and ardize care.• Some evidence exists for the effectiveness of quality improvement approaches to improve the management of bronchiolitis . What is New:• NICE guidance can be effectively applied to a department using simple educational tools.• Effective NICE implementation reduces the rates of unnecessary chest radiograph and antibiotic administration for patients admitted with bronchiolitis in District General Hospitals Optimal management of children with perforated appendicitis remains a controversial clinical problem . Until very recently , the criteria for hospital discharge on our surgical service included the absence of fever and leukocytosis for a period of 48 hours following completion of antimicrobial therapy , uncomplicated wound healing , a normal rectal examination , and unimpaired gastrointestinal function . With the introduction of cost-containment programs , the necessity for the period of inpatient observation following cessation of antibiotics was question ed . The records of 87 consecutive children with perforated appendicitis were analyzed prospect ively in order to determine if our discharge policies were medically sound and cost-effective . Seventy-five patients ( 86 % ) recovered uneventfully while 12 children required prolonged hospitalization for management of various postoperative complications . The 12 patients who developed complications were all identifiable early in the postoperative period because of persistent fever , leukocytosis , and elevated b and counts . Of the 75 children who recovered uneventfully , all met st and ard discharge criteria on the final day of antibiotic therapy with the exception of completing the m and atory 48-hour period of inpatient observation . These children were maintained in the hospital a total of 142 additional days following discontinuation of antibiotics . The average cost per patient day for children with perforated appendicitis during the study period was $ 506.32 , which represented unnecessary hospital charges of $ 71,897.44 . It was concluded that inpatient observation following cessation of antibiotic therapy in children who experience an uneventful recovery from perforated appendicitis is neither necessary nor cost-effective . ( ABSTRACT TRUNCATED AT 250 WORDS PURPOSE To evaluate whether antibiotics without surgery is sufficient treatment for children with clinical ly and ultrasonographically suspected acute appendicitis ( AA ) . METHOD Children with clinical , laboratory and radiological findings suspicious for AA were evaluated prospect ively . Patients with mild clinical signs , without peritonitis were considered for IV followed by oral antibiotics without surgery . RESULTS From 1 November 2013 through 30 June 2014 , 45 children were diagnosed with early , acute appendicitis . Ages ranged from 4 to 15 years ( mean 9.3 ) and 32 ( 75 % ) were boys . All had routine , clinical laboratory and ultrasound workup . Forty-two improved with antibiotic treatment and were discharged home within 3 - 5 days , without surgery . Three of them were operated on within 24 hours , another two underwent appendectomy for recurrent appendicitis : one at 2 weeks and the other 2 months after discharge . There was no more recurrent appendicitis in 6 - 14-month follow-up . CONCLUSION Our series of patients with AA treated with antibiotics only are a product of the observation that some children improve with antibiotics alone at a stage in which surgery is still debatable . These results ( 89 % success rate ) support the conservative approach in cases of early appendicitis , without increased morbidity in failed cases PURPOSE Although many patients receive antibiotic therapy for uncomplicated appendicitis , the relatively high treatment failure and recurrence rates are problematic . We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm , have better outcomes . The purpose of this prospect i ve non-r and omized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm . METHODS Over 2 years , we enrolled 119 patients who initially received antibiotic therapy .  The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis . Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively . We evaluated the rates of treatment failure , peritonitis , and recurrence . RESULTS Nine patients ( 7.6 % ) failed to respond to initial antibiotic therapy , and 6 had true appendicitis after subsequent surgery . Two patients had complicated appendicitis ( peritonitis ) , but no patient displayed intra-abdominal abscess postoperatively . During a median follow-up period months of 14 months , 14 patients ( 12.7 % ) experienced recurrence . CONCLUSIONS Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm BACKGROUND Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial . We studied the results of initial conservative treatment ( antibiotics and percutaneous drainage if necessary , with or without interval appendectomy ) compared with immediate surgery . METHODS We undertook an observational , retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon , treated in our hospital between January 1997 and March 2009 . Patients younger than 14 , with severe sepsis or with diffuse peritonitis were excluded . A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment . A control group was composed of the other patients , who all underwent  urgent appendectomy  , matched for age and later r and omized 1:1 . The infectious risk stratification was established with the National Nosocomial Infections Surveillance System ( NNIS ) index . Dependent variables were hospital stay and surgical site infection . Analysis was with SPSS , with p < 0.05 considered significant . RESULTS Interval appendectomy  was performed in 7 study group patients . Surgical site infection episodes were more frequent in the control group ( 6 vs. 0 , p < 0.001 ) . A greater percentage of high risk patients ( NNIS ≥ 2 ) was identified in the control group ( 80 vs. 28.7 % , p < 0.03 ) , mostly related with contaminated or dirty procedures in this group ( p < 0.001 ) . No significant difference between groups was found in hospital stay . CONCLUSION Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon The clinical guideline on the prevention of  venous thromboembolism ( VTE ) applicable to all hospital patients was published by the National Institute for Health and Clinical Excellence ( NICE ) in January 20101 with considerable media attention . We believe that adherence to this guidance will save lives that might otherwise be lost due to preventable pulmonary embolism ( PE ) . After the guideline launch , NICE and the Chair of Guideline Development Group ( GDG ) received many e-mails from doctors and members of the public including everything from extremely well-argued and robust challenges , through common misconceptions , to highly individualized personal perspectives . We are prompted by some recurring themes , or what might be called ‘ frequently asked questions ’ , to address some of these issues . The clinical guideline recommends that the first step is that all patients should be assessed at or before hospital admission . This involves a ‘ checklist ’ . The checklist approach has been found to save lives when applied to surgical operations2 and yet it is met with resistance and scorn by some doctors.3 Who would be impressed to discover that the airline pilot had skipped the preflight checklist because he found it a bore ? There is safety for the majority in a checklist – otherwise , while concentrating , quite rightly , on the immediate clinical problems of the particular medical admission or surgical operation we might forget important elements of the background safety drills . In the case of hospital-acquired VTE and its prevention , the checklist has been developed in collaboration between GDG and the Chief Medical Officer 's Working Group and will be implemented with the backing of the Department of Health . The checklist is design ed to be inclusive so that opting out of VTE prophlyaxis should be a conscious decision . Any tick against VTE risk prompts reference to the NICE clinical guideline . Some of our e-mails came from doctors who describe a patient in whom slavish adherence to guidelines would seem to them illogical . A guideline is there to guide not dictate ; it can not be made to fit 100 % of situations . Finding a loophole in the guideline does not discredit it in its entirety . The checklist should be implemented in 100 % of admissions but clinical exclusion result ing in , for example , 90 % compliance might well be about right . Health professionals should use good sense and clinical judgement in applying guidance to individual patients – but be prepared to defend a decision not to follow it . A problem with clinical judgement is that a recent memorable disaster tips the balance . Powerful evidence for this effect was found in the not dissimilar clinical question of anticoagulation of patients in atrial fibrillation to reduce the risk of stroke.4,5 If one of their patients had a bleed , doctors were less likely to prescribe anticoagulants in subsequent patients ; a single event in their recent experience weighed more heavily than the total published evidence . But perhaps worse , if an untreated patient had a stroke , no alteration in practice occurred . So , altering practice on the basis of experience is not even-h and ed : errors of commission weigh more heavily than errors of omission . The background to the VTE guidance is the reported common failure to prevent death due to PE.6 VTE prophylaxis with anticoagulants is not 100 % effective and is not 100 % safe . That is why all risks are carefully considered by the GDG and their consequences weighed in terms of QALYs lost and gained . The guideline attempts to find the nadir of risk for all our patients rather than the individual comfort zone of doctors . We have been asked specifically why we did not include children with inflammatory bowel disease , patients with cancer on the waiting list , and why a relative 's life was not saved after admission to hospital with a PE . Our answer to all of these questions , and many others like them is that they are outside our ‘ scope ’ . The frame or boundaries within which we offer guidance are determined at the beginning of the process and governs the search for evidence which may include many thous and s of papers , and after exclusion of many in the case of VTE , over 400 r and omized controlled trials ( RCTs ) remained for analysis . Each of these was critically appraised and meta-analysed and health economic models constructed for the particular setting . So the apparently simple matters of defining a hospital admission and how to categorize a day-case have to be agreed by the GDG . Others might have made other choices but the decisions were not reached without much deliberation . There are other working decisions that had to be made at the outset . If you come into hospital for the common elective operations such as cholecystectomy or hip replacement , a PE is the most likely thing to kill you . Are we entitled to use risk reductions from RCTs where the outcome was asymptomatic DVT to inform strategies to reduce deaths due to PE ? If not , we severely curtail the evidence base . Fatal PE occurs at a statistically low rate and trials powered with PE as an endpoint would require many tens of thous and s of patients . A form of common cause hypothesis7 is generally agreed for VTE and has been the premise of teaching and practice for years ( Figure1 ) . Thus , asymptomatic DVT , PE , and death due to PE event rates have a reasonably stable ratio one to another . Does this always apply ? Does it apply to knee surgery for instance ? It is arguable that local surgical causes may increase the rate for detectable DVT in knee surgery which do not share a common cause with fatal PE and then the ratio breaks down . The question can only be resolved by gaining and interpreting the evidence . We may need more . Figure 1 There is generally accepted to be a continuum between  asymptomatic DVT and fatal PE  , with a common underlying pathological cause . We have used Heinrich 's triangle to illustrate this . If the commoner events at the triangle 's base are reduced then there ... Not all setting s have been studied . The largest part of the evidence is in surgical patients and most of that is in general surgery and orthopaedics . An ENT surgeon correctly points out that there is no direct evidence that applies to his practice . But there are biological triggers related to surgery and the degree of reduced mobility entailed for its performance and recovery which have a degree of commonality . Either the GDG generalizes the available evidence on VTE risk and its modification , or offers no guidance at all for a very large number of patients having operations for which evidence was not specifically acquired . A doctor can still make a clinical judgement to deviate from guidance for an individual patient , but it would be wise to document this decision , with the reason . Extrapolation from one setting to another is itself a judgement . In one instance , the GDG had to modify guidance at the 11th hour when faced with new evidence in the use of graduated compression stockings . The existing evidence was that stockings reduced risk of VTE by about 50 % based on studies in surgical patients . Furthermore , mechanical methods are without risk of bleeding and so their use seemed a reasonable first resort in patients for whom there is clinical concern about even a small bleeding risk , such those with stroke . Then the CLOTS study reported that in patients admitted with stroke , there was no reduction in VTE risk with thigh-length stockings versus no stockings and a small but definite burden of harm related to skin pressure.8 In the face of this direct evidence against them , we could not recommend stockings for patients with stroke . But what did this evidence do for other extrapolations ? Should the new CLOTS evidence be applied in non-stroke medical patients or should we use the evidence gained in surgical patients ? This was not straightforward and was discussed at length by the GDG and a consensus reached . We wonder what others would have done ? There are other gaps in direct evidence . More recently introduced drugs have never been examined in a placebo-controlled trial . In RCTs they have been compared with the best existing drugs . To overcome this limitation , an ingenious and mathematically sophisticated method of incorporating all RCT evidence and without breaking r and omization has been developed , called network meta- analysis ( Figure 2).9 Readers of guidance should be mindful of the amount of work and level of sophistication that goes into NICE guideline development , particularly if the guidance is at odds with their previous practice . The opinions of individual doctors on a case-by-case basis are not a satisfactory way of preventing VTE . It is not possible to compute , on the basis of experience , the relative numerical risks of VTE versus bleeding ; both events occur too infrequently and there are too many other variables . Furthermore , decisions made on the basis of experience respond to recent events and discount remote events . It is a clinical question for which the NICE method of careful evaluation of all available evidence is at its most useful and we believe has clear advantages over known alternatives . Figure 2 General surgery : outcome DVT . Network meta- analysis constructed so that indirect comparisons can be made . For example fondaparinux was only compared with the then ‘ best ’ existing agent , low molecular weight heparin . VKA : vitamin K antagonists ; OBJECTIVE The aim of the present study is to determine the feasibility and safety of antibiotics for uncomplicated simple appendicitis in pregnancy . METHOD We conducted a 6-year prospect i ve observational study on 20 pregnant women in whom uncomplicated simple appendicitis ( appendiceal diameter ≤11 mm and with no signs of appendicoliths , perforation , or abscess ) was radiologically verified and managed with a 4-day course of antibiotics . Treatment failure rate , defined as the need for an appendectomy during hospitalization and recurrence in the follow-up period ( median 25 months ) , and maternal or fetal complications during the pregnancy were evaluated . RESULTS Mean age of patients was 33.4 years , and gestational age was 17.8 weeks . Three patients failed to respond to antibiotic therapy  during hospitalization and underwent subsequent appendectomy ( 2 suppurative and 1 perforated appendicitis ) . There was 1 wound infection postoperatively . During follow-up , 2 patients during their ongoing pregnancy experienced recurrence at 3 and 6 months post-treatment , and a new course of antibiotics was determined . Patients also experienced recurrence at 8 and 10 months post-treatment and underwent appendectomy . Treatment failure occurred in 5 patients ( 25 % ) with no fetal complications during the pregnancy . CONCLUSIONS Antibiotic therapy for uncomplicated appendicitis in pregnancy may be a feasible treatment option without severe maternal and fetal complications To demonstrate the efficacy of oral metronidazole ( OM ) in simple or complicated appendicitis with localized peritonitis , a r and omized prospect i ve study was carried out in 1083 patients , ranging in age from 4 to 50 years ( mean age , 21.38 ) . The patients were r and omly divided into two groups . The study group ( SG ) ( 524 patients ) received OM ( 500 mg for adults , 7 - 10 mg/kg if less than 15 years ) 2 - 3 hours before operation . The drug was continued 4 to 5 hours after operation , every 8 hours , for three doses if the appendix was mild to severely inflamed . In the case of complicated appendicitis ( 114 patients ) , the same dose was given for 3 to 6 days , depending on the absence or presence of pus . Ceftizoxime was administered to the control group ( CG ) ( 559 patients ) 2 to 3 hours before operation and then postoperatively every 6 hours for three doses if the appendix was mild to severely inflamed . The complicated cases in the CG ( 120 patients ) received a combination of penicillin , chloramphenicol , and gentamicin for 3 to 6 days , depending on the absence or presence of pus . The serum concentration of metronidazole  measured in 43 patients was at bactericidal level in 40 ( mean + /- SD st and ard deviation , 10.65 + /- 4.89 microg/mL ) . The rate of wound infection was not significantly different in the SG and the CG with the same degree of pathology ( 3.17 % vs 2.96 % if uncomplicated ; 15.78 % vs 14.16 % if complicated , respectively ) . Pelvic collection occurred in four adults and one child in the CG with perforated appendicitis ( 4.16 % ) . The same complication developed in two adults and two children in the SG with perforated appendicitis ( 3.5 % ) . All six adults and one of the children in the SG had to be re-explored , whereas the remaining two children responded to conservative management  ( OM and gentamicin ) . In uncomplicated cases , hospital stay and hospital charge were both almost the same in both groups . However , length of hospitalization was nearly 1 day shorter and hospital cost per day was about 30 per cent less in complicated cases in the SG as compared with the CG . Conclusively , OM may not only substitute parenteral antibiotics in acute appendicitis as a prophylactic agent , but it may also be used as a cost-effective drug and is more convenient to the patient Study objective R and omized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics‐first is safe . No trial has evaluated outpatient treatment and no US r and omized trial has been conducted , to our knowledge . This pilot study assessed feasibility of a multicenter US study comparing antibiotics‐first , including outpatient management , with appendectomy . Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were r and omized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole . Stable antibiotics‐first‐treated participants older than 13 years could be discharged after greater than or equal to 6‐hour emergency department ( ED ) observation with next‐day follow‐up . Outcomes included 1‐month major complication rate ( primary ) and hospital duration , pain , disability , quality of life , and hospital charges , and antibiotics‐first appendectomy rate . Results Of 48 eligible patients , 30 ( 62.5 % ) consented , of whom 16 ( 53.3 % ) were r and omized to antibiotics‐first  and 14 ( 46.7 % ) to appendectomy . Median age was 33 years ( range 9 to 73 years ) , median WBC count was 15,000/&mgr;L ( range 6,200 to 23,100/&mgr;L ) , and median computed tomography appendiceal diameter was 10 mm ( range 7 to 18 mm ) . Of 15 antibiotic‐treated adults , 14 ( 93.3 % ) were discharged from the ED and all had symptom resolution . At 1 month , major complications occurred in 2 appendectomy participants ( 14.3 % ; 95 % confidence interval [ CI ] 1.8 % to 42.8 % ) and 1 antibiotics‐first participant ( 6.3 % ; 95 % CI 0.2 % to 30.2 % ) . Antibiotics‐first participants had less total hospital time than appendectomy participants , 16.2 versus 42.1 hours , respectively . Antibiotics‐first‐treated participants had less pain and disability . During median 12‐month follow‐up , 2 of 15 antibiotics‐first‐treated participants ( 13.3 % ; 95 % CI 3.7 % to 37.9 % ) developed appendicitis and 1 was treated successfully with antibiotics ; 1 had appendectomy . No more major complications occurred in either group . Conclusion A multicenter US trial comparing antibiotics‐first to appendectomy , including outpatient management , is feasible to evaluate efficacy and safety BACKGROUND / PURPOSE Imaging techniques are used widely to diagnose appendicitis . However , the negative appendectomy rate remains at about 15 % . The authors assessed ultrasound-based decision making in the treatment of acute appendicitis in children . METHODS The authors prospect ively studied 165 consecutive children ( 3 to 15 years old ) evaluated for appendicitis . Diagnosis and treatment were based solely on ultrasound scan findings . Criterion for appendicitis was a diameter exceeding 6 mm . Severity was classified into 4 grade s based on the appearance of intramural appendiceal structure . Patients with grade s I or II received antibiotic therapy . Patients with grade s III or IV underwent appendectomy . RESULTS Ultrasound scan diagnosed appendicitis in 93 children ( grade I , 7 ; grade II , 17 ; grade III , 41 ; and grade IV , 28 ) . All but 2 patients with grade s I or II underwent  antibiotic therapy  without complication . All grade s III or IV patients underwent appendectomy . There was no negative appendectomy among 76 appendectomies during this period . Ultrasound-based prediction of severity was correct in 67 cases ( 88 % ) . Ultrasonography identified other pathology in 39 . CONCLUSIONS Ultrasonography in children can not only visualize all inflamed appendices but also predict severity of disease . Treatment based entirely on ultrasound scan identified patients who required surgery for severe appendicitis and permitted successful conservative treatment for mild appendicitis Importance Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis , but long-term outcomes are not known . Objective To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis . Design , Setting , and Participants Five-year observational follow-up of patients in the Appendicitis Acuta ( APPAC ) multicenter r and omized clinical trial comparing appendectomy with antibiotic therapy , in which 530 patients aged 18 to 60 years with computed tomography – confirmed uncomplicated acute appendicitis were r and omized to undergo an appendectomy ( n = 273 ) or receive antibiotic therapy ( n = 257 ) . The initial trial was conducted from November 2009 to June 2012 in Finl and ; last follow-up was September 6 , 2017 . This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone . Interventions Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole . Main Outcomes and Measures In this analysis , prespecified secondary end points reported at 5-year follow-up included late ( after 1 year ) appendicitis recurrence after antibiotic treatment , complications , length of hospital stay , and sick leave . Results Of the 530 patients ( 201 women ; 329 men ) enrolled in the trial , 273 patients ( median age , 35 years [ IQR , 27 - 46 ] ) were r and omized to undergo appendectomy , and 257 ( median age , 33 years , [ IQR , 26 - 47 ] ) were r and omized to receive antibiotic therapy . In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year ( 27.3 % [ 95 % CI , 22.0%-33.2 % ] ; 70/256 ) , 30 additional antibiotic-treated patients ( 16.1 % [ 95 % CI , 11.2%-22.2 % ] ; 30/186 ) underwent appendectomy between 1 and 5 years . The cumulative incidence of appendicitis recurrence was 34.0 % ( 95 % CI , 28.2%-40.1 % ; 87/256 ) at 2 years , 35.2 % ( 95 % CI , 29.3%-41.4 % ; 90/256 ) at 3 years , 37.1 % ( 95 % CI , 31.2%-43.3 % ; 95/256 ) at 4 years , and 39.1 % ( 95 % CI , 33.1%-45.3 % ; 100/256 ) at 5 years . Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis , 76 had uncomplicated appendicitis , 2 had complicated appendicitis , and 7 did not have appendicitis . At 5 years , the overall complication rate ( surgical site infections , incisional hernias , abdominal pain , and obstructive symptoms ) was 24.4 % ( 95 % CI , 19.2%-30.3 % ) ( n = 60/246 ) in the appendectomy group and 6.5 % ( 95 % CI , 3.8%-10.4 % ) ( n = 16/246 ) in antibiotic group ( P < .001 ) , which calculates to 17.9 percentage points ( 95 % CI , 11.7 - 24.1 ) higher after surgery . There was no difference between groups for length of hospital stay , but there was a significant difference in sick leave ( 11 days more for the appendectomy group ) . Conclusions and Relevance Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis , the likelihood of late recurrence within 5 years was 39.1 % . This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis . Trial Registration Clinical Trials.gov Identifier : BACKGROUND Emerging literature has supported the safety of nonoperative management of uncomplicated appendicitis . STUDY DESIGN Patients with emergent , uncomplicated appendicitis were identified by appropriate ICD-9 diagnosis codes in the California Office of Statewide Health Planning and Development data base from 1997 to 2008 . Rates of treatment failure , recurrence , and perforation after nonsurgical management were calculated . Factors associated with treatment failure , recurrence , and perforation were identified using multivariable logistic regression . Mortality , length of stay , and total charges were compared between treatment cohorts using matched propensity score analysis . RESULTS Of 231,678 patients with uncomplicated appendicitis , the majority ( 98.5 % ) were managed operatively . Of the 3,236 nonsurgically managed patients who survived to discharge without an interval appendectomy , 5.9 % and 4.4 % experienced treatment failure or recurrence , respectively , during a median follow-up of more than 7 years . There were no mortalities associated with treatment failure or recurrence . The risk of perforation after discharge was approximately 3 % . Using multivariable analysis , race and age were significantly associated with the odds of treatment failure . Sex , age , and hospital teaching status were significantly associated with the odds of recurrence . Age and hospital teaching status were significantly associated with the odds of perforation . Matched propensity score analysis indicated that after risk adjustment , mortality rates ( 0.1 % vs 0.3 % ; p = 0.65 ) and total charges ( $ 23,243 vs $ 24,793 ; p = 0.70 ) were not statistically different between operative and nonoperative patients ; however , length of stay was significantly longer in the nonoperative treatment group ( 2.1 days vs 3.2 days ; p < 0.001 ) . CONCLUSIONS This study suggests that nonoperative management of uncomplicated appendicitis can be safe and prompts additional investigations . Comparative effectiveness research using prospect i ve r and omized studies can be particularly useful
Although pain was a common criterion for nonresponse and appendectomy , analgesic regimens were poorly described .
BACKGROUND Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery .
However , guidance as to specific management does not exist .