Antibiotics or Surgery for Appendicitis, An Unfair Choice For Patients (Right Now)

Antibiotics (without surgery) for appendicitis is the latest trending topic in surgery. Despite the fact that research is still ongoing, many surgeons are jumping to offer antibiotics as an alternative to surgery for appendicitis.  We know that an antibiotics-only approach is still quasi-experimental. Because we cannot be confident that antibiotics is effective long-term, some surgeons choose to offer both options (surgery or antibiotics) and let the patient decide.

It is an unfair decision for patients. First of all, surgeons offering antibiotics likely do not have adequate time to sufficiently educate their patient. The tendency is to over-simplify and say: “we recommend surgery, but you can also choose antibiotics.” Most rational people would avoid surgery if there’s a reasonable alternative. Second, even the doctors don’t have complete data.  Until the research is complete, we should only be recommending the best, proven treatment (surgery) unless the patient refuses surgery or surgery is unsafe in that patient. For now, we should only be using antibiotics to treat appendicitis in a controlled research setting.

But the reality is that antibiotics for appendicitis is already creeping into clinical practice. Here’s the full story, as well as what I would tell my patients.

For decades, patients with appendicitis have undergone urgent surgery to remove the appendix. It’s safe and effective, with a very low complication rate. Patients recover quickly, even leaving the hospital the same day of surgery. The appendix has no function, so life goes back to normal. There’s no question that it is the gold standard of treatment for appendicitis. Many surgeons will agree that anything less is irresponsible or sub-optimal patient care. 

So far, there has only been one good research study about antibiotics for appendicitis in adults. (Also one in children). (There have also been a handful of European trials that suffer from poor selection of patients, excessive number of patients changing their minds). The first research study has not gone on for very long — they stopped and looked at their data after 1 year. Keep in mind that these studies only give antibiotics to people with uncomplicated appendicitis; severe cases still get surgery.

Based on that study, here’s what we know about antibiotics for surgery:

  • There’s a 1 in 20 chance you won’t get better, and will need surgery before leaving the hospital
  • There’s a 1 in 4 chance you will have recurrent symptoms and need surgery within the first year

Without a doubt, those are good results (depending on how you look at it). Put another way, that means there’s a ~75% chance that patients treated with antibiotics won’t need surgery in that first year. The problem is that we don’t know what happens after that first year. It’s possible that your risk of appendicitis goes back to normal. It’s also possible that the risk remains at 25% per year. It’s hard to balance these numbers against a surgery that is >99% effective.

I fully believe antibiotics for appendicitis is worth studying. I’ve published a study about the cost-effectiveness of antibiotics for appendicitis, and am actively researching antibiotics for appendicitis as well. But it’s still too soon to put out in the news, and too soon to start recommending to patients.

 

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