A role for conservative antibiotic treatment in early appendicitis in children. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. A randomized comparative study of sulbactam plus ampicillin vs. metronidazole plus cefotaxime in the management of acute appendicitis in children. Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study. Perioperative prophylaxis with sulbactam and ampicillin compared with metronidazole and cefotaxime in the prevention of wound infection in children undergoing appendectomy. Peritoneal lavage versus drainage for perforated appendicitis in children Ultrasound-based decision making in the treatment of acute appendicitis in children. Laparoscopy in children with complicated appendicitis. Laparoscopic versus conventional surgery for suspected appendicitis in women Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis. Antibiotics‐First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial) Are antibiotics necessary in nonperforated appendicitis in children? A double blind randomized controlled trial. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prospective Multicenter Randomized Controlled Trial Acute nonperforating appendicitis. Efficacy of brief antibiotic prophylaxis. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial.
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 OBJECTIVE The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children . METHODS A pilot r and omized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children . Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were r and omized either to treatment with antibiotics or to surgery . Follow-up was for 1 year . RESULTS Fifty patients were enrolled ; 26 were r and omized to surgery and 24 to nonoperative treatment with  antibiotics . All children in the surgery group had histopathologically confirmed acute appendicitis , and there were no significant complications in this group . Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis . Another 6 patients have had an appendectomy due to recurrent abdominal pain ( n = 5 ) or parental wish ( n = 1 ) during the follow-up period ; none of these 6 patients had evidence of appendicitis on histopathological examination . CONCLUSIONS Twenty-two of 24 patients ( 92 % ) treated with antibiotics had initial resolution of symptoms . Of these 22 , only 1 patient ( 5 % ) had recurrence of acute appendicitis during follow-up . Overall , 62 % of patients have not had an appendectomy during the follow-up period . This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted Sulbactam is a beta-lactamase inhibitor that , when combined with ampicillin , gives the latter antibiotic a broad spectrum of activity , making it suitable for use as a prophylactic agent in acute appendicitis . In a single-blind , r and omized trial , the efficacy of sulbactam plus ampicillin was compared with that of metronidazole plus cefotaxime .  Thirty-five children undergoing appendectomy received intravenous sulbactam and ampicillin , while 38 children received metronidazole and cefotaxime . Single doses were given unless the appendix was considered gangrenous or perforated , in which case the drugs were administered for 72 hr . There were three wound infections in the group given sulbactam and ampicillin and five in the group given metronidazole and cefotaxime . The combination of sulbactam and ampicillin was well tolerated and appeared to be at least as effective as that of metronidazole and cefotaxime in the prevention of sepsis following appendectomy BACKGROUND Initial antibiotic treatment for acute appendicitis has been shown to be safe in adults ; so far , not much is known about the safety and efficacy of this treatment in children . The aims of this study were to investigate the feasibility of a r and omized controlled trial ( RCT ) evaluating initial antibiotic treatment for acute appendectomy in children with acute simple appendicitis and to evaluate the safety of this approach . METHODS In a multicenter , prospect i ve cohort study patients aged 7 - 17 years with a radiologically confirmed simple appendicitis were eligible .  Intravenous antibiotics ( amoxicillin/clavulanic acid 250/25 mg/kg 4 times daily ; maximum 6,000/600 mg/d and gentamicin 7 mg/kg once daily ) were administered for 48 - 72 hours . Clinical reevaluation every 6 hours , daily blood sample s , and  ultrasound follow-up  after 48 hours was performed . In case of improvement after 48 hours , oral antibiotics were given for a total of 7 days . At any time , in case of clinical deterioration or non-improvement after 72 hours , an appendectomy could be performed . Follow-up continued until 8 weeks after discharge . Adverse events were defined as major complications of antibiotic treatment , such as allergic reactions , perforated appendicitis , and recurrent appendicitis . RESULTS Of 44 eligible patients , 25 participated ( inclusion rate , 57 % ; 95 % CI , 42%-70 % ) . Delayed appendectomy was performed in 2 , and the other 23 were without symptoms at the 8 weeks follow-up . Minor complications occurred in three patients . None of the patients suffered from an adverse event or a recurrent appendicitis . CONCLUSION Our study shows that an RCT comparing initial antibiotic treatment strategy with urgent appendectomy is feasible in children ; the intervention seems to be safe Sulbactam is a beta-lactamase inhibitor , which when administered with ampicillin , increases the latter agents antibacterial activity against beta-lactamase producing organisms . One hundred children between the ages of 5 and 14 undergoing emergency appendectomy were entered into a prospect i ve r and omized trial comparing sulbactam and ampicillin ( SA ) with metronidazole and cefotaxime ( MC ) as prophylaxis against postoperative wound infection .  Patients in whom the appendix was perforated or gangrenous received a 72-hour course of antibiotics , others received a single dose only . The overall wound infection rate was 8 % ( 14 % in patients with perforation or gangrene and 4 % in those without ) . There was no difference in infection rate between the two antibiotic groups ; there were three wound infections and one subphrenic abscess in patients receiving SA and four wound infections in patients receiving MC . SA , therefore , appears to be a suitable antibiotic combination for use as prophylaxis in appendicitis in children A total of 231 children with acute appendicitis were treated at our hospitals during the 10 years between 1984 and 1993 , 53 of whom had a perforated appendix . These 53 patients were r and omly assigned to two groups at the time of surgery according to the different procedures performed . Thus , 29 children were managed by appendectomy followed by peritoneal lavage using a large amount of saline , and intravenous antibiotic therapy consisting of aminoglycoside and cephem ( lavage group ) , while the other 24 children were treated by appendectomy with silicon tube drainage and the same systemic antibiotic therapy ( drainage group ) . The mean length of hospitalization , and the mean duration s of fever and the need for fasting after laparotomy in the lavage group were significantly less than those in the drainage group : 10.1 versus 18.8 days , 2.8 versus 7.7 days , and 1.8 versus 3.5 days , respectively . The operation wounds healed well in the lavage group due to the fact that there was no drain . Wound infections occurred in two children from the lavage group and six from the drainage group . Intra-abdominal abscesses occurred in two children from the drainage group . Accordingly , peritoneal lavage appears to be superior to intraperitoneal tube drainage for the management of perforated appendicitis in children 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 BACKGROUND / PURPOSE Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children . The role of laparoscopy in complicated acute appendicitis is more controversial . The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis . METHODS A total of 102 children with suspected acute appendicitis were selected r and omly to undergo either a laparoscopic or an open appendectomy . The outcomes of 25 children with complicated appendicitis , 13 in the laparoscopic group and 12 in the open appendectomy group , were analyzed . Children , their parents , and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation . All 25 children completed a 30-day follow-up . RESULTS There were no differences in terms of patients ' age , sex , weight , height , and appendiceal histology between the 2 groups . All laparoscopic procedures were completed without conversion . The mean ( + /-SD ) operating time was 63 ( + /-31 ) minutes in the laparoscopic group and 37 ( + /-18 ) minutes in the open appendectomy group ( mean difference 26 minutes , 95 % CI 5 to 47 minutes , P = .02 ) . There were 2 major complications in the laparoscopic group in children with appendiceal masses . One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation . Another child had a pelvic abscess that resolved with antibiotic treatment . Superficial wound infections were encountered in 2 patients in the open appendectomy group . CONCLUSIONS Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis . Good surgical judgement is necessary in patients with an established appendiceal abscess The diagnosis of appendicitis remains uncertain in female patients and laparoscopy has been suggested as a valid diagnostic tool . The laparoscopic approach has recently also been proposed for the treatment of acute appendicitis , though its real value is still under debate . A clinical and economic prospect i ve evaluation of laparoscopic surgery over a 1-year period in female patients is reported . The study involved 38 patients presenting with signs of appendicitis and assigned to open ( 18 ) or laparoscopic surgery ( 20 ) . The two groups were comparable as regards age and clinical presentation of the disease . The duration of the procedures was similar ( 60 min ) . Morbidity was comparable ( 3 vs 2 ) . The ratio of negative appendectomy ( 50 % vs 44 % ) was also similar , but the laparoscopic approach enabled a higher number of certain diagnoses ( 9/10 vs 3/8 p>0.05 ) . No significant differences were observed in the median postoperative stay ( 3 days for laparoscopy and 4 for surgery ) or in the days needed to return to normal activity ( 15 vs 18 ) . The cosmetic satisfaction was higher for the laparoscopic patients . The cost of the laparoscopic approach , however , was much higher than for conventional surgery . Our results suggest that laparoscopy is a useful diagnostic tool in female patients , but that laparoscopic appendectomy should be considered with some caution in times of restricted financial re sources 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 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 HYPOTHESIS For children with perforated appendicitis , the use of a prolonged course of intravenous ( i.v . ) antibiotics is equivalent to a short course of i.v . antibiotics followed by sequential conversion to oral ( PO ) antibiotics . DESIGN Prospect i ve , r and omized , clinical trial . SETTING Multicenter study in tertiary children 's hospitals . PATIENTS Children ( aged 5 - 18 years ) with perforated appendicitis found at laparotomy . INTERVENTION Children were r and omized after appendectomy either to a 10-day course of a combination of i.v . ampicillin , gentamicin sulfate , and clindamycin ( n = 10 ) ; or to a short course of a combination of i.v . ampicillin , gentamicin , and clindamycin , followed by conversion to a combination of p.o . amoxicillin and clavulanate potassium plus metronidazole ( n = 16 ) . MAIN OUTCOME MEASURES The primary outcome measure was clinical success , which was rated as complete , partial , or failure . Secondary outcome measures included return of oral intake , duration of fever , return of normal white blood cell count , and patient charges . Treatment equivalence was determined using confidence interval analysis . RESULTS We found treatment equivalence between the i.v . and i.v./p.o . groups , with 6 ( 60 % ) complete and 4 ( 40 % ) partial successes for the 10 patients in the i.v . group and 15 ( 94 % ) complete and 1 ( 6 % ) partial successes for the 16 patients in the i.v./p.o . group ( P < or = .05 ) . There was no difference in return of oral intake , duration of fever , or return of normal white blood cell count between the groups . Conversion to oral therapy results in savings of approximately $ 1500 per case . CONCLUSION There is treatment equivalence between prolonged i.v . therapy and i.v . therapy followed by conversion to oral antibiotic therapy in children with perforated appendicitis 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 INTRODUCTION Perforated appendicitis is a common condition in children , which , in a small number of patients , may be complicated by a well-formed abscess . Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy . Although this strategy has become well accepted , there are no published data comparing initial nonoperative management ( drainage/interval appendectomy ) to appendectomy upon presentation with an abscess . Therefore , we conducted a r and omized trial comparing these 2 management strategies . METHODS After internal review board approval ( # 06 11 - 164 ) , children who presented with a well-defined abdominal abscess by computed tomographic imaging were r and omized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess  ( when possible ) , followed by interval laparoscopic appendectomy approximately 10 weeks later . This was a pilot study with a sample size of 40 , which was based on our recent volume of patients presenting with appendicitis and abscess . RESULTS On presentation , there were no differences between the 2 groups regarding age , weight , body mass index , sex distribution , temperature , leukocyte count , number of abscesses , or greatest 2-dimensional area of abscess in the axial view . Regarding outcomes , there were no differences in length of total hospitalization , recurrent abscess rates , or overall charges . There was a trend toward a longer operating time in patients undergoing initial appendectomy ( 61 minutes versus 42 minutes mean , P = .06 ) . CONCLUSIONS Although initial laparoscopic appendectomy trends toward a requiring longer operative time , there seems to be no advantages between these strategies in terms of total hospitalization , recurrent abscess rate , or total charges 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 The use of antibiotics in uncomplicated appendicitis in children , remains the area of controversy . The aim of the study was to assess the necessity of antibiotic administration in nonperforated appendicitis in children . MATERIAL AND METHODS The design of the study was a double blind r and omized controlled trial , with a follow-up of 4 to 20 months . SETTING Surgical Department in a University Pediatric Hospital . PATIENTS One hundred and eighty seven out of 249 children subjected to emergency appendectomies met the inclusion criteria , with 35 eligible but not included in the study . The remaining 152 patients were r and omized ; 41 had complicated appendicitis , 3 other diagnosis , 108 were analyzed within 3 study groups : 1 ( n = 31 ) no antibiotic , 2 ( n = 41 ) one dose , 3 ( n = 36 ) 5-day course . Open appendectomy was a surgical procedure and Ceftriaxone 1.0 g i.v . was administered . Investigated parameters were : body temperature , WBC , bowel sounds , wound healing , recovery and morbidity . RESULTS Valid outcome data were available for 90 of 108 r and omized patients . Protocol s of 18 children due to fever > 39 degrees C , upper airway infection or allergy were disclosed . In the remaining 90 children , there were no differences in WBC and oral feeding between groups 1 ( n = 24 ) , 2 ( n = 35 ) and 3 ( n = 31 ) . Group 1 and 2 had a higher mean temperature on day 1 post-op , without any clinical significance . A higher mean temperature was noted on day 5 post-op in group 1 , due to wound infection in one patient . There were no intraabdominal abscesses . The only other complications were 2 adhesion small bowel obstructions ( in groups 1 and 2 each ) . CONCLUSION Routine use of antibiotics in nonperforated appendicitis in children is not necessary 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 Appendectomy has been the treatment for acute appendicitis for over 120 years . Antibiotic treatment has occasionally been used in small uncontrolled studies , instead of operation , but this alternative has never before been tried in a multicenter r and omized trial . Patients and Methods Male patients , 18–50 years of age , admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study . No women were enrolled by decision of the local ethics committee . If appendectomy was planned , patients were asked to participate , and those who agreed were r and omized either to surgery or to antibiotic therapy . Patients r and omized to surgery were operated on with open surgery or laparoscopically . Those r and omized to antibiotic therapy were treated intravenously for 2 days , followed by oral treatment for 10 days . If symptoms did not resolve within 24 hours , an appendectomy was performed . Participants were monitored at the end of 1 week , 6 weeks , and 1 year . Results During the study period 252 men participated , 124 in the surgery group and 128 in the antibiotic group .  The frequency of appendicitis was 97 % in the surgery group and 5 % had a perforated appendix . The complication rate was 14 % in the surgery group . In the antibiotic group 86 % improved without surgery ; 18 patients were operated on within 24 hours , and the diagnosis of acute appendicitis was confirmed in all but one patient , and he was suffering from terminal ileitis . There were seven patients ( 5 % ) with a perforated appendix in this group . The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14 % during the 1-year follow-up . Conclusions Acute nonperforated appendicitis can be treated successfully with antibiotics . However , there is a risk of recurrence in cases of acute appendicitis , and this risk should be compared with the risk of complications after appendectomy A prospect i ve , r and omized , double-blind clinical study was performed to determine the efficacy of perioperative systemic antibiotics in preventing infection after appendectomy for acute nonperforating appendicitis . One hundred three patients received three doses of either placebo ( saline , n = 52 ) or cefoxitin sodium ( n = 51 ) . The two groups were similar with regard to age distribution , sex ratio , duration of operation , pathologic condition of appendix , and hospital stay . Postoperative wound infections were detected in 9.6 % of the placebo-treated patients , whereas none occurred in the cefoxitin group . All but one infection appeared after discharge . Cost analysis identified a net savings of $ 84 per patient with the use of prophylactic antibiotics . Septic morbidity after appendectomy for nonperforating appendicitis is significantly reduced by systemic antibiotics , and brief administration of a single broad-spectrum agent ( cefoxitin ) is effective prophylaxis INTRODUCTION In a previous prospect i ve r and omized trial , we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient , cost-effective treatment for children with perforated appendicitis . In this study , we evaluated the safety of discharging patients to complete an oral course of antibiotics . METHODS Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study . Perforation was defined as a hole in the appendix or fecalith in the abdomen . Patients were r and omized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days ( intravenous [ IV ] arm ) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet ( IV/PO arm ) to complete 7 days . RESULTS One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis . On presentation , there were no differences in age , weight , sex distribution , days of symptoms , maximum temperature , or leukocyte count between the 2 groups . There was no difference in the postoperative abscess rate between the two treatment groups . Discharge was possible before day 5 in 42 % of the patients in the IV/PO arm . CONCLUSIONS When patients are able to tolerate a regular diet , completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation INTRODUCTION Appendicitis is the most common emergency condition in children . Historically , a 3-drug regimen consisting of ampicillin , gentamicin , and clindamycin ( AGC ) has been used postoperatively for perforated appendicitis . A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole ( CM ) to be a more simple and cost-effective antibiotic strategy . Therefore , we performed a prospect i ve , r and omized trial to compare efficacy and cost-effectiveness of these 2 regimens . METHODS After internal review board approval ( IRB no. 04 12 - 149 ) , children found to have perforated appendicitis at appendectomy were r and omized to either once daily dosing of CM ( 2 total doses per day ) or st and ard dosing of AGC ( 11 total doses per day ) . Perforation was defined as an identifiable hole in the appendix . The operative approach ( laparoscopic ) , length of antibiotic use , and criteria for discharge were st and ardized for the groups . Based on our retrospective analysis using length of postoperative hospitalization as a primary end point , a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82 . RESULTS One hundred patients underwent laparoscopic appendectomy for perforated appendicitis . On presentation , there were no differences in sex distribution , days of symptoms , temperature , or leukocyte count . There was no difference in abscess rate or wound infections between groups . The CM group result ed in significantly less antibiotic charges then the AGC group . CONCLUSIONS Once daily dosing with the 2-drug regimen ( CM ) offers a more efficient , cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen
There was no consistency among the protocol s regarding length of antibiotic use , discharge criteria , or use of home antibiotics following discharge .
Limiting duration of antibiotic use to3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection .
In the absence of higher-level evidence , shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe
The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated .