title: Appendectomy versus antibiotic treatment for acute appendicitis.
abstract: BACKGROUND
  Acute appendicitis is one of the most common causes of acute abdominal pain. Present day treatment of choice for acute appendicitis is appendectomy, however complications are inherent to operative treatment. Though surgical appendectomy remains the standard treatment, several investigators have investigated conservative antibiotic treatment of acute appendicitis and reported good results.
  
  
  OBJECTIVE
  Is antibiotic treatment as effective as surgical appendectomy (laparoscopic or open) in patients with acute appendicitis on recovery within two weeks, without major complications (including recurrence) within one year?
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 6, 2011); MEDLINE (until June 2011); EMBASE (until June 2011); Prospective Trial Registers (June 2011) and reference lists of articles.
  
  
  METHODS
  Randomised and quasi-randomised clinical trials (RCT and qRCT) comparing antibiotic treatment with appendectomy in patients with suspected appendicitis were included. Excluded were studies which primarily focused on the complications of acute appendicitis.
  
  
  METHODS
  Two authors independently assessed trial quality and extracted data. The review authors contacted the trial authors for additional information if required. Statistical analysis was carried out using Review Manager and MetaAnalyst. A non-inferiority analysis was performed, comparing antibiotic treatment (ABT) to the gold standard (appendectomy). By consensus, a 20% margin of non-inferiority was considered clinically relevant.
  
  
  RESULTS
  Five RCT's (901 patients) were assessed. In total 73.4% (95% CI 62.7 to 81.9) of patients who were treated with antibiotics and 97.4 (95% CI 94.4 to 98.8) patients who directly got an appendectomy were cured within two weeks without major complications (including recurrence) within one year. The lower 95% CI was 15.2% below the 20% margin for the primary outcome.
  
  
  CONCLUSIONS
  The upper bound of the 95% CI of ABT for cure within two weeks without major complications crosses the 20% margin of appendectomy, so the outcome is inconclusive. Also the quality of the studies was low to moderate, for that reason the results should be interpret with caution and definite conclusions cannot be made. Therefore we conclude that appendectomy remains the standard treatment for acute appendicitis. Antibiotic treatment might be used as an alternative treatment in a good quality RCT or in specific patients or conditions were surgery is contraindicated.
authors.affiliation: Department of Emergency Medicine,VieCuri Medical Centre of Northern Limburg, Venlo, Netherlands.
authors.forename: Ingrid M H A
authors.initials: IM
authors.lastname: Wilms
authors.forename: Dominique E N M
authors.initials: DE
authors.lastname: de Hoog
authors.forename: Dianne C
authors.initials: DC
authors.lastname: de Visser
authors.forename: Heinrich M J
authors.initials: HM
authors.lastname: Janzing
mesh_terms: D000208:Acute Disease; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001062:Appendectomy / Q000379:methods*; D001064:Appendicitis / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D016032:Randomized Controlled Trials as Topic
chemical_list: D000900:Anti-Bacterial Agents