title: Protocol-based approach to suspected appendicitis, incorporating the Alvarado score and outpatient antibiotics.
abstract: BACKGROUND
  There is evidence that antibiotics can be used as primary treatment for appendicitis, however, delayed surgical treatment might still be associated with perforation. Most patients at risk of perforation have high Alvarado scores. We designed a protocol-based approach to suspected appendicitis, in which the Alvarado score was used to select patients for early treatment with surgery or outpatient antibiotics.
  
  
  METHODS
  Patients included in the present study were adults and children referred to the surgical service at John Hunter Hospital (Newcastle, Australia) with suspected appendicitis in the 12 months from July 2000. Treatment groups: no treatment (Alvarado score 1-4); antibiotics alone (Alvarado 5-7); early surgery (Alvarado 8-10).
  
  
  METHODS
  time to operation; duration of hospital stay; non-therapeutic operations; delayed treatment in association with perforation; recurrent appendicitis (for those treated with antibiotics). Comparison group: 142 patients managed with 'best clinical practice' as part of an earlier trial.
  
  
  RESULTS
  One hundred and twenty-two patients were enrolled. Median time to operation was 3.9 h (comparison group 7.3 h, P = 0.014). Median length of stay was 38.5 h (comparison group 44.2 h, P = 0.041). There were two cases of delayed treatment in association with perforation (2/122 = 1.6%, comparison group 2/142 = 1.4%, P = 0.88) and 10 non-therapeutic operations (10/122 = 8.1%, comparison group 15/142 = 10.6%, P = 0.51). Of those whose initial illness was treated successfully with antibiotics, 2/42 (4.8%) subsequently required appendicectomy.
  
  
  CONCLUSIONS
  This protocol-based approach to suspected appendicitis is feasible. A prospective controlled study would be required to confirm potential benefits (in terms of short hospital stay) and to confirm that there is not an increase in adverse outcomes.
authors.affiliation: Division of Surgery, John Hunter Hospital, and University of Newscastle, New South Wales, Australia.
authors.forename: Robert D
authors.initials: RD
authors.lastname: Winn
authors.forename: Sharon
authors.initials: S
authors.lastname: Laura
authors.forename: Charles
authors.initials: C
authors.lastname: Douglas
authors.forename: Patricia
authors.initials: P
authors.lastname: Davidson
authors.forename: Jon S
authors.initials: JS
authors.lastname: Gani
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001064:Appendicitis / Q000175:diagnosis* / Q000188:drug therapy* / Q000601:surgery; D002648:Child; D002985:Clinical Protocols; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D008297:Male; D018579:Patient Selection; D018709:Statistics, Nonparametric
chemical_list: D000900:Anti-Bacterial Agents