title: The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis.
abstract: OBJECTIVE
  To assess the safety and efficacy of antibiotics treatment for suspected acute uncomplicated appendicitis and to monitor the long term follow-up of non-operated patients.
  
  
  BACKGROUND
  Right lower quadrant abdominal pain is a common cause of emergency department admission. The natural history of acute appendicitis nonoperatively treated with antibiotics remains unclear.
  
  
  METHODS
  In 2010, a total of 159 patients [mean AIR (Appendicitis Inflammatory Response) score = 4.9 and mean Alvarado score = 5.2] with suspected appendicitis were enrolled and underwent nonoperative management (NOM) with amoxicillin/clavulanate. The follow-up period was 2 years.
  
  
  RESULTS
  Short-term (7 days) NOM failure rate was 11.9%. All patients with initial failures were operated within 7 days. At 15 days, no recurrences were recorded. After 2 years, the overall recurrence rate was 13.8% (22/159); 14 of 22 patients were successfully treated with further cycle of amoxicillin/clavulanate. No major side effects occurred. Abdominal pain assessed by the Numeric Rating Scale and the visual analog scale; median Numeric Rating Scale score was 3 at 5 days and 2 after 7 days. Mean length of stay of nonoperatively managed patients was 0.4 days, and mean sick leave period was 5.8 days. Long-term efficacy of NOM treatment was 83% (118 patients recurrence free and 14 patients with recurrence nonoperatively managed). None of the single factors forming the Alvarado or AIR score were independent predictors of failure of NOM or long-term recurrence. Alvarado and AIR scores were the only independent predictive factors of NOM failure after multivariate analysis, but both did not correlate with recurrences. Overall costs of NOM and antibiotics were &OV0556;316.20 per patient.
  
  
  CONCLUSIONS
  Antibiotics for suspected acute appendicitis are safe and effective and may avoid unnecessary appendectomy, reducing operation rate, surgical risks, and overall costs. After 2 years of follow-up, recurrences of nonoperatively treated right lower quadrant abdominal pain are less than 14% and may be safely and effectively treated with further antibiotics.
authors.affiliation: *Trauma Surgery Unit, Maggiore Hospital Regional Trauma Center, Bologna Local Health District, AUSL, Bologna, Italy †I Unit, General and Emergency and Trauma Surgery, Ospedali Riuniti, Bergamo, Italy ‡Department of Surgery, Hospital of Macerata, Macerata, Italy; and §Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy.
authors.forename: Salomone
authors.initials: S
authors.lastname: Di Saverio
authors.forename: Andrea
authors.initials: A
authors.lastname: Sibilio
authors.forename: Eleonora
authors.initials: E
authors.lastname: Giorgini
authors.forename: Andrea
authors.initials: A
authors.lastname: Biscardi
authors.forename: Silvia
authors.initials: S
authors.lastname: Villani
authors.forename: Federico
authors.initials: F
authors.lastname: Coccolini
authors.forename: Nazareno
authors.initials: N
authors.lastname: Smerieri
authors.forename: Michele
authors.initials: M
authors.lastname: Pisano
authors.forename: Luca
authors.initials: L
authors.lastname: Ansaloni
authors.forename: Massimo
authors.initials: M
authors.lastname: Sartelli
authors.forename: Fausto
authors.initials: F
authors.lastname: Catena
authors.forename: Gregorio
authors.initials: G
authors.lastname: Tugnoli
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015746:Abdominal Pain / Q000175:diagnosis / Q000628:therapy; D000208:Acute Disease; D000658:Amoxicillin / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001062:Appendectomy; D001064:Appendicitis / Q000175:diagnosis / Q000628:therapy; D019818:Clavulanic Acid / Q000627:therapeutic use; D003937:Diagnosis, Differential; D004359:Drug Therapy, Combination; D005500:Follow-Up Studies; D011446:Prospective Studies; D012008:Recurrence; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000658:Amoxicillin; D000900:Anti-Bacterial Agents; D019818:Clavulanic Acid