Antibiotic therapy continues to be a viable long-term option for adult patients with uncomplicated acute appendicitis, according to 10-year follow-up data from the Appendicitis Acuta (APPAC) multicenter randomized clinical trial published in JAMA.
The analysis examined long-term outcomes among patients originally randomized to antibiotic therapy rather than appendectomy, and found that more than half avoided surgery over a decade of follow-up. The results extend earlier findings from the APPAC trial, which previously reported outcomes through five years.
The original APPAC trial enrolled 530 adult patients aged 18 to 60 years with computed tomography (CT)–confirmed uncomplicated acute appendicitis at six participating hospitals in Finland between 2009 and 2012. Patients were randomized to either open appendectomy or antibiotic therapy consisting of intravenous ertapenem followed by oral levofloxacin and metronidazole. The current observational follow-up assessed appendicitis recurrence, appendectomy rates, complications, quality of life, and the potential for undetected appendiceal tumors.
At 10 years, nearly all patients initially assigned to antibiotic therapy were available for recurrence assessment. Among these patients, 38% experienced a confirmed recurrence of appendicitis, and 44% ultimately underwent appendectomy during the follow-up period. Most recurrences and surgeries occurred within the first two years following initial treatment, with relatively few events occurring later in the decade.
Despite the recurrence rate, the investigators noted that antibiotic therapy remained durable for many patients. More than half of those treated initially with antibiotics avoided surgery altogether during the 10-year follow-up. Importantly, no cases of complicated acute appendicitis were identified at one year among patients initially treated with antibiotics, and only a small number of complicated cases occurred later.
Long-term safety outcomes also favored antibiotic therapy. The cumulative complication rate over 10 years was lower among patients initially randomized to antibiotics compared with those who underwent appendectomy. Complications in both groups were generally mild, with few new events reported beyond five years.
Concerns have persisted that nonoperative management of appendicitis could delay the diagnosis of appendiceal tumors, particularly in older adult patients. To address this, the investigators incorporated magnetic resonance imaging at 10 years for patients in the antibiotic group who retained their appendix. Among those who underwent imaging, two patients were found to have low-grade appendiceal mucinous neoplasms and underwent appendectomy. No additional treatment was required. Overall, the prevalence of appendiceal tumors was low and did not differ meaningfully between treatment groups.
Quality-of-life outcomes were similar between patients randomized to antibiotics and those who underwent appendectomy. Patient satisfaction remained high in both groups, particularly among patients who successfully avoided surgery. Most patients who did not require appendectomy following antibiotic therapy reported they would choose the same treatment again.
The study was led by Paulina Salminen, MD, PhD, of the Department of Surgery at the University of Turku, Finland, and colleagues. The researchers emphasized that antibiotic therapy is appropriate only for carefully selected patients with imaging-confirmed uncomplicated appendicitis and without features associated with a higher risk of treatment failure, such as appendicolith.
Current international guidelines already recognize antibiotics as a treatment option for uncomplicated acute appendicitis. The investigators noted that these long-term results support shared decision-making, allowing physicians and patients to weigh the likelihood of recurrence against the potential to avoid surgery and its associated risks.
Disclosures can be found in the article.
Source: JAMA Network
