title: Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection. Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. Long-Term Results Following Antibiotic Treatment of Acute Appendicitis in Adults Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prospective Multicenter Randomized Controlled Trial Efficacy of Short-Term Antibiotic Therapy for Consecutive Patients with Mild Appendicitis Expanding the inclusion criteria for nonoperative management of uncomplicated appendicitis: Outcomes and cost. A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial) Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. Association between Appendectomy and Subsequent Colorectal Cancer Development: An Asian Population Study Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Non‐operative Management for Uncomplicated Appendicitis: An Option to Consider A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues? Antibiotics‐First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management Non-operative management of early, acute appendicitis in children: is it safe and effective? Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis High failure rate of nonoperative management of acute appendicitis with an appendicolith in children. Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial. Effect of preoperative rectal indomethacin on postoperative pain reduction after open appendectomy. Comparison of operative and non operative management of acute appendicitis. A role for conservative antibiotic treatment in early appendicitis in children. Initial antibiotic treatment for acute simple appendicitis in children is safe: Short-term results from a multicenter, prospective cohort study. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm.
abstract: METHODS We r and omly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever , leukocytosis , and ileus , with a maximum of 10 days of therapy ( control group ) , or to receive a fixed course of antibiotics ( experimental group ) for 4±1 calendar days . The primary outcome was a composite of surgical-site infection , recurrent intraabdominal infection , or death within 30 days after the index source -control procedure , according to treatment group . Secondary outcomes included the duration of therapy and rates of subsequent infections 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 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 PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options Background Antibiotic treatment of acute appendicitis has gained interest and inquiries . Reports have demonstrated both safety and high resolution of symptoms and inflammation following antibiotic treatment of appendicitis , but information on long-term results is required . Our present aim was therefore to evaluate long-term recurrence rate of initial antibiotics-alone treatment for suspected acute appendicitis . Methods Patients with favourable response to antibiotics in earlier r and omized ( RCT , n = 97 ) and population -based ( PBT , n = 342 ) studies as well as subsequently treated non-r and omized ( Non-R , n = 271 ) patients are evaluated for long-term risk to relapse dem and ing surgical appendectomy ; altogether 710 patients . Results Clinical characteristics among r and omized and non-r and omized patients were similar without any statistical difference according to abdominal symptoms and degree of systemic inflammation ( CRP , WCC ) when antibiotic treatment started . Females and males showed the same results . The median follow-up time was 2162 days ( 5.92 years ) , and the range across highest and lowest follow-up was 3495 days ( range 2–3497 ) for the entire group , without significant differences among subgroups ( RCT , PBT , Non-R ) . The cumulative probability for relapse of appendicitis dem and ing appendectomy was : 0.09 , 0.12 , 0.12 and 0.13 at 1- , 2- , 3- and 5-year follow-up , with a probability of 0.86 ± 0.013 without appendectomy after 8 years . This may imply an overall benefit of 60–70 % by antibiotics during expected 10-year follow-up accounting for initial treatment failures at 10–23 % in our published reports . Conclusion Antibiotic treatment is safe and effective as a first-line therapy in unselected adults with acute appendicitis with a risk around 15 % for long-term relapse following favourable initial treatment response 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 Although antibiotic therapy seemed to be a safe treatment option for acute appendicitis , indications of this treatment have not been fully evaluated . We hypothesized that clinical and radiologic mild appendicitis may be a c and i date for short-term antibiotic therapy . The purpose of present study was to examine the efficacy and the recurrence rate of short-term antibiotic therapy for consecutive patients with mild appendicitis . A prospect i ve observational study was conducted over 3 years . The mild appendicitis was defined as the intermediate Alvarado score ( 4 - 8 ) and dilated appendix from 6 mm to 10 mm in radiologic study . All patients received initial antibiotics administration with clinical observation during 48 hours . The failure to respond to therapy and the incidence of recurrence were assessed . There were 107 enrolled patients with the mean Alvarado score of 6 ± 1 and the mean appendiceal diameter of 7.4 ± 1 mm . Of these , 97 ( 91 % ) exhibited improved symptoms and were discharged . The remaining 10 patients underwent surgery because of clinical aggravation , and pathology revealed true appendicitis in six of them . Of the 97 patients in whom the initial treatment was successful , five patients ( 5 % ) exhibited recurrent symptoms during a median follow-up period of 18 months . Of these five patients , three were treated with surgery ( all true appendicitis ) , and the remaining two were once again treated with antibiotics . Patients with suspected appendicitis , those in whom mild appendicitis was diagnosed after clinical and radiologic evaluations , were found to benefit from short-term antibiotic therapy 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 ) 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 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 Objectives The appendix may modulate colon microbiota and bowel inflammation . We investigated whether appendectomy alters colorectal cancer risk . Methods We identified a cohort of 75979 patients who underwent appendectomy between 1997 and 1999 based on the insurance cl aims of Taiwan . A comparison cohort of 303640 persons without appendectomy was selected r and omly , frequency matched by age , sex , comorbidity and entry year was also selected . We monitored subsequent colorectal cancer development in both cohorts . Results The overall colorectal cancer incidence was 14 % higher in the appendectomy patients than in the comparison cohort ( p < 0.05 ) : the highest incidence was observed for rectal cancer , and the lowest incidence was observed for cancer of the cecum-ascending colon for both cohorts . Men were at higher risk than women . Subjects ≥ 60 years had an HR of 12.8 compared to those < 60 years . The incidence of colorectal cancer was much higher in 1.5 - 3.5 years post appendectomy follow-up than for the comparisons ( HR of 2.13 ) . Patients who received an incidental appendectomy had an HR of 2.90 when compared to the comparisons . Conclusions Results of our study suggest that appendectomy in patients with appendicitis is likely associated with the development of colorectal cancer in the post-surgery period 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 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 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 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 PURPOSE The purpose of this study was to determine if early , acute appendicitis in children can be safely and effectively managed with antibiotics alone . METHODS A retrospective review was performed of children ( < 18 yrs ) treated non-operatively ( NOM ) for early , acute appendicitis since May 2012 . These were compared to patients treated with appendectomy between January 2011 and October 2011 ( OM ) . Inclusion criteria included : ( a ) symptoms < 48 h , ( b ) localized peritonitis , and ( c ) ultrasound findings consistent with early , acute appendicitis . RESULTS Twelve patients ( 66 % female , mean age 12.2,SD=4.2 yrs ) were treated non-operatively , while 12 ( 50 % female , mean age 12.5,SD=3.2 yrs ) were treated operatively . Two NOM children ( 16.7 % ) required initial appendectomy . One patient developed recurrent appendicitis requiring appendectomy 7 months post-discharge . Four other NOM patients returned with symptoms but did not require admission or surgery . Two OM patients ( 8.3 % ) had hospital visits and admissions related to surgical site infections . Mean length of stay ( LOS ) for the first visit was 1.5 days ( SD=1.0d ) ( NOM ) vs. 1.3 days ( SD=0.5d ) ( OM ) ( p=0.61 ) . Including first and subsequent admissions , mean LOS was 1.8 days ( SD=1.1d ) ( NOM ) vs. 1.7 days ( SD=1.5d ) ( OM ) ( p=0.97 ) . CONCLUSION Early acute appendicitis in appropriately selected children can be successfully treated non-operatively . R and omized trials with longer follow-up are required 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 BACKGROUND The purpose of this study was to investigate the feasibility of  nonoperative management of acute appendicitis in children with an appendicolith identified on preoperative imaging . STUDY DESIGN We performed a prospect i ve nonr and omized trial of nonoperative management of uncomplicated acute appendicitis with an appendicolith in children aged 7 to 17years . The primary outcome was the failure rate of nonoperative management , defined as having undergone an appendectomy . Early termination was set to occur if the lower limit of the 95 % confidence interval of the failure rate was greater than 20 % at 30days or 30 % at 1year . RESULTS Recruitment for this study was halted after enrollment of 14 patients ( N=5 nonoperative ; N=9 surgery ) . The failure rate of nonoperative management was 60 % ( 3/5 ) at a median follow-up of 4.7months ( IQR 1.0 - 7.6 ) with a 95 % CI of 23%-88 % . None of the three patients that failed nonoperative management had complicated appendicitis at the time of appendectomy , while six out of nine patients who chose surgery had complicated appendicitis ( 0/3 vs. 6/9 , p=0.18 ) . The trial was stopped for concerns over patient safety . CONCLUSIONS Nonoperative management of acute appendicitis with an appendicolith in children result ed in an unacceptably high failure rate 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 BACKGROUND Because of concerns about masking important physical findings , there is controversy surrounding whether it is safe to provide analgesia to patients with undifferentiated abdominal pain . The purpose of this study was to address the effects of analgesia on the physical examination and diagnostic accuracy for patients with abdominal pain . STUDY DESIGN The study was a prospect i ve , double-blind clinical trial in which adult Emergency Department ( ED ) patients with undifferentiated abdominal pain were r and omized to receive placebo ( control group , n = 36 ) or morphine sulphate ( MS group , n = 38 ) . Diagnostic and physical examination assessment s were recorded before and after a 60-minute period during which study medication was titrated . Diagnostic accuracy and physical examination changes were compared between groups using univariate statistical analyses . RESULTS There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy . The overall likelihood of change in severity of tenderness was similar in MS ( 37.7 % ) as compared with control ( 35.3 % ) patients ( risk ratio [ RR ] 1.07 , 95 % confidence interval [ CI ] 0.64 - 1.78 ) . MS patients were no more likely than controls to have a change in pain location ( 34.0 % versus 41.2 % , RR 0.82 , 95 % CI 0.50 - 1.36 ) . Diagnostic accuracy did not differ between MS and control groups ( 64.2 % versus 66.7 % , RR 0.96 , 95 % CI 0.73 - 1.27 ) . There were no differences between groups with respect to likelihood of any change occurring in the diagnostic list ( 37.7 % versus 31.4 % , RR 1.20 , 95 % CI 0.71 - 2.05 ) . Correlation with clinical course and final diagnosis revealed no instance of masking of physical examination findings . CONCLUSIONS Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain BACKGROUND One of the major challenges faced by the treatment planning teams is how to manage postoperative pain . Previous studies agreed upon the effects of preoperative administration of nonsteroidal anti-inflammatory drugs on postoperative pain , but all have focused on patients with surgical noninflammatory diseases ( ie , inguinal hernia or breast biopsy ) . The aim of this study was to evaluate the effects of rectal indomethacin on reducing postoperative pain in patients with acute appendicitis . METHODS It is a simple r and omized , clinical trial including 200 patients with acute appendicitis who were divided into two groups ( A1 and A2 ) . The case group ( A1 ) received 100 mg rectal indomethacin during 2 hours before the operation . Pain intensity was assessed in all patients using a visual analog scale ( VAS ) . Similarly , total dosage of meperidine analgesic medication and postoperative time to use of rescue analgesia were evaluated . RESULTS Patients who received preoperative rectal indomethacin ( A1 ) showed a significant reduction in the VAS score . Also , a reduction in total dose of meperidine and longer time to use of rescue analgesic medication were observed in A1 group . CONCLUSION Preoperative administration of rectal indomethacin in acute appendicitis reduces postoperative pain BACKGROUND In this prospect i ve study , operative and nonoperative management of acute appendicitis were evaluated regarding their safety and cost effectiveness . METHODS Two hundred ninety patients presenting to our Emergency Department between March 2005 and March 2006 with acute appendicitis were included in this prospect i ve study . Nonoperative medical therapy was performed in 107 patients ( Group 1 ) , and 183 patients were treated surgically ( Group 2 ) . Routine follow-up controls were done on the 10th day , at the 3rd and 6th months and at the first year after discharge in Group 1 . Both groups were compared regarding age , gender , mean hospital stay , modified Alvarado score , morbidity , mortality , and cost effectiveness . RESULTS The male/female ratio of Groups 1 and 2 were 65/42 ( mean age : 30.98+/-1.30 ) and 125/58 ( mean age : 26.25+/-0.79 ) , respectively . In Group 1 , 19 patients were operated . Operation indications were resistance to therapy , patient 's request , and operation in another hospital . Although the mean hospital stay of Group 1 was statistically significantly longer than Group 2 , the mean cost of the therapy was $ 559 in Group 2 and $ 433 in Group 1 . Morbidity rates were similar , with no mortality in either group . CONCLUSION With its high success rate and cost effectiveness , medical treatment seems to be a good alternative to the gold st and ard therapy of surgery in management of acute appendicitis 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 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 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 : 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
target: Although pain was a common criterion for nonresponse and appendectomy , analgesic regimens were poorly described .
background: 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 .