title: Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics.
abstract: BACKGROUND
  Acute appendicitis is the most common surgical diagnosis in young patients, with lifetime prevalence of about 7%. Debate remains on whether uncomplicated AA should be operated or not. Aim of this meta-analysis of randomized controlled trials was to assess current evidence on antibiotic treatment for uncomplicated AA compared to standard surgical treatment.
  
  
  METHODS
  Systematic literature search was performed using PubMed, EMBASE, Medline, Google Scholar and Cochrane Central Register of Controlled Trials databases for randomized controlled trials comparing antibiotic therapy (AT) and surgical therapy-appendectomy (ST) for uncomplicated AA. Trials were reviewed for primary outcome measures: treatment efficacy based on 1 year follow-up, recurrence at 1 year follow-up, complicated appendicitis with peritonitis identified at the time of surgical operation and post-intervention complications. Secondary outcomes were length of hospital stay and period of sick leave.
  
  
  RESULTS
  Five RCTs comparing AT and ST qualified for inclusion in meta-analysis, with 1.351 patients included: 632 in AT group and 719 in ST group. Higher rate of treatment efficacy based on 1 year follow-up was found in ST group (98.3% vs 75.9%, P < 0.0001), recurrence at 1 year was reported in 22.5% of patients treated with antibiotics. Rate of complicated appendicitis with peritonitis identified at time of surgical operation was higher in AT group (19.9% vs 8.5%, P = 0.02). No statistically significant differences were found when comparing AT and ST groups for the outcomes of overall post-intervention complications (4.3% vs 10.9%, P = 0.32), post-intervention complications based on the number of patients who underwent appendectomy (15.8% vs 10.9%, P = 0.35), length of hospital stay (3.24 ± 0.40 vs 2.88 ± 0.39, P = 0.13) and period of sick leave (8.91 ± 1.28 vs 10.27 ± 0.24, P = 0.06).
  
  
  CONCLUSIONS
  With significantly higher efficacy and low complication rates, appendectomy remains the most effective treatment for patients with uncomplicated AA. The subgroups of patients with uncomplicated AA where antibiotics can be more effective, should be accurately identified.
authors.affiliation: General, Emergency and Minimally Invasive Surgery, San Francesco Hospital, Nuoro, Italy. Electronic address: mauropodda@ymail.com.
authors.forename: Mauro
authors.initials: M
authors.lastname: Podda
authors.affiliation: General and Oncologic Surgery, Santissima Trinità Hospital, ASL8, Cagliari, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Cillara
authors.affiliation: Emergency and Trauma Surgery, Maggiore Hospital, Bologna, Italy.
authors.forename: Salomone
authors.initials: S
authors.lastname: Di Saverio
authors.affiliation: General, Emergency and Minimally Invasive Surgery, San Francesco Hospital, Nuoro, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Lai
authors.affiliation: General and Oncologic Surgery, Santo Stefano Hospital, Prato, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Feroci
authors.affiliation: Surgical Oncology, Businco Hospital, AOB, Cagliari, Italy.
authors.forename: Gianluigi
authors.initials: G
authors.lastname: Luridiana
authors.affiliation: General Surgery Department, ULSS19 del Veneto, Rovigo, Italy.
authors.forename: Ferdinando
authors.initials: F
authors.lastname: Agresta
authors.affiliation: General Surgery, Montichiari Surgery, ASST Spedali Civili di Brescia, Brescia, Italy.
authors.forename: Nereo
authors.initials: N
authors.lastname: Vettoretto
mesh_terms: D000208:Acute Disease; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000009:adverse effects* / Q000627:therapeutic use; D001062:Appendectomy; D001064:Appendicitis / Q000150:complications / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D010538:Peritonitis / Q000209:etiology*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000900:Anti-Bacterial Agents
keywords: Acute appendicitis; Antibiotic therapy; Appendectomy; Meta-analysis; Non-operative management; Systematic review; Un-complicated appendicitis