ANTIBIOTICS FOR APPENDICITIS: AN ALTERNATIVE TO SURGERY

Appendectomy, the surgical removal of the appendix, has been the standard treatment of appendicitis for over 100 years.

Doctors often prescribe antibiotics to treat an infection before appendicitis surgery. Sometimes antibiotics are prescribed after the surgery if the appendix has ruptured.

Recently, treatment with antibiotics only has been proposed as an alternative to surgery in patients with uncomplicated appendicitis. But are antibiotics alone enough to treat an inflamed appendix? 

Continue reading to learn more about treating appendicitis with antibiotics alone, the success rate, and whether it should be tried first before surgery.

What Is Appendicitis?

Appendicitis is a painful condition where the appendix becomes inflamed and swollen.

The appendix is a small, tube-shaped pouch attached to the large intestines in the lower right side of your abdomen (belly).

The common belief was that this organ was a remnant of evolution with no significant function in the body’s physiology. Although scientists still don’t know the exact role of the appendix, recent studies have shown that it may play an important role in boosting the body’s immune response against invading pathogens.

An inflamed appendix can cause pain on and off in the lower right side of the abdomen. In most people, the pain starts around the belly button, then spreads down.

People who develop appendicitis usually need to have their appendix removed as soon as possible. A burst (ruptured) appendix can cause sudden, severe pain and a serious infection known as peritonitis (an infection inside the abdominal cavity).

The signs and symptoms of appendicitis often present suddenly and worsen with time. They may include:

• Abdominal pain that starts on the lower right side of the abdomen
• Pain that starts around the belly button and then spreads to the lower right side of the belly
• Abdominal pain that worsens when you cough, sneeze or move abruptly 
• Diarrhea or constipation
• A low-grade fever
• Bloating or swelling in the belly
• Loss of appetite
• Inability to pass gas (flatulence)

Set an appointment with your doctor if you experience any of the above symptoms. Sudden severe abdominal pain requires immediate medical care.

How Is Appendicitis Treated?

If appendicitis isn’t treated quickly, it can rupture and release harmful bacteria into your abdominal cavity. When the bacteria spread, they can cause a potentially life-threatening infection known as peritonitis. 

Appendix removal surgery (appendectomy) is the standard treatment for appendicitis. For over 100 years, doctors have been treating inflamed appendices by surgically removing them.

An appendectomy can be performed as an open surgery (laparotomy) with one incision about 5 to 10 centimeters long. Laparoscopic appendix removal surgery is another option involving a few small abdominal incisions.

Laparoscopic appendectomies require less recovery time and have fewer risks of complications. However, laparoscopic surgery is not for everyone. You may need major abdominal surgery (laparotomy) if your appendix has ruptured, the infection has spread, or in case of an abscess.

Patients often receive antibiotics before and sometimes after surgery to clear up the infection in the appendix.

In some cases, doctors may use antibiotics instead of surgery if the appendicitis is uncomplicated. 

Treating Appendicitis With Antibiotics

Before an appendectomy, surgeons usually administer broad-spectrum IV antibiotics effective against a wide range of bacteria.

Common antibiotics used to manage appendicitis include:

• Ampicillin and Sulbactam (Unasyn)
• Cefazolin with Metronidazole
• Ceftriaxone (Rocephin) with Metronidazole
• Cefotetan
• Cefoxitin
• Clindamycin (Cleocin)
• Gentamicin (Garamycin)
• Imipenem with Cilastatin
• Piperacillin with Tazobactam (Zosyn)
• Ticarcillin with Clavulanate

After an appendectomy, you may need to continue your antibiotic therapy to prevent postoperative infections, especially if the appendix had ruptured. 

Recently, studies have shown that acute, uncomplicated cases of appendicitis may be treated with antibiotics alone. In cases that do not involve a ruptured appendix, peritonitis, or abscesses, surgery may not be necessary. An antibiotics-only therapy can clear appendicitis in such scenarios.

Are Antibiotics Alone Enough To Treat Appendicitis?

Antibiotics as a first-line treatment for appendicitis

In 2012, researchers analyzed four randomized clinical trials to investigate whether antibiotics can be used safely as primary treatment in patients with acute uncomplicated appendicitis.

The trials included 900 adult patients, half of whom randomly received antibiotics as the first treatment, and the other half underwent surgery to remove the appendix.

One year later, the antibiotic-first treatment had a 63% success rate and a reduced risk of complications compared to appendectomy. Around 20% of patients treated with only antibiotics eventually underwent appendectomy a year later because of recurring symptoms.

The authors concluded that antibiotics can be considered a safe initial treatment option for uncomplicated appendicitis. 

A similar trial was done between 2009 and 2012 in Finland, and the results were published in 2015. The study included 530 participants with uncomplicated acute appendicitis. Patients randomly received either early appendectomy or antibiotic treatment and followed up a year later.

Most patients in the antibiotic group (around 73%) did not need surgery one year after the treatment. Out of 27% who subsequently needed surgery, only 10% experienced complications.

Researchers suggested that treating patients who did not have complications again with antibiotics might have been enough to cure their symptoms.

A more recent randomized trial in 2020 investigated how effective it is to treat patients with uncomplicated appendicitis with just antibiotics. It included 1552 adults with uncomplicated appendicitis from 25 different centers.

Patients received either antibiotics or appendectomy first and got assessed three months later.

After three months, nearly 70% of participants (7 out of 10) were successfully treated with antibiotics alone and did not require surgery. The other 30% (3 out of 10) eventually had to undergo an appendectomy.

However, 41% of patients who needed surgery after initial antibiotic treatment had an appendicolith (a stone-like calcification inside the appendix). These results indicate that the antibiotics treatment approach is more likely to fail in patients with an appendicolith.

The authors concluded that although patients can recover from appendicitis with an antibiotics-first treatment and without surgery, this approach doesn’t work for everyone.

Treating appendicitis with antibiotics vs. surgery 

Clinical trials show that treating uncomplicated appendicitis with antibiotics without surgery has the following advantages:

• Avoid surgery and anesthesia
• Recovery is faster when compared to surgery (patients treated with antibiotics alone missed fewer days of work on average than those treated with surgery) 
• No risk of the appendix rupturing

On the other hand, patients treated with immediate surgery are less likely to return to the hospital after the initial treatment.

The American College Of Surgeons warns that an antibiotic-only treatment has a higher chance of recurrence. Appendicitis can come back after antibiotics treatment.

A five-year follow-up study suggests that around 40% of patients treated with antibiotics for uncomplicated acute appendicitis require surgery within five years. 

Should antibiotics replace appendectomy as the first-line treatment for appendicitis?

Appendectomy remains the standard treatment for complicated appendicitis (ruptured or perforating).

However, there has been growing evidence supporting the effectiveness of antibiotics as the first-line treatment for uncomplicated appendicitis. Nevertheless, the question remains, should patients with uncomplicated appendicitis undergo appendix removal surgery first or antibiotics-only treatment first?

Still, some researchers believe appendectomy remains the gold-standard treatment of uncomplicated appendicitis. That’s because patients who undergo immediate surgery for appendicitis are less likely to require further treatment later. 

Individuals with appendicitis should be aware of all their treatment options and the success rate of each approach. Patients with an appendicolith are less likely to benefit from an antibiotics-only strategy and more likely to need surgery after some time. 

In 2015, a case report suggested that an antibiotics-first approach should be considered in patients who wish to avoid surgery or have a high risk of complications from surgery.

Some patients might want to avoid surgery and try the antibiotics-first treatment option, knowing that it may or may not work and they may need to return to the hospital for surgery later.

Others might prefer immediate surgery to ensure they wouldn’t need treatment again, even though it would take longer to recover from an appendectomy. 

Knowing the risks and success rates, patients can discuss their options with their physicians and decide on the best course of treatment.

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Sources from the scientific literature: 

• Antibiotics alone in the treatment of appendicitis - PMC
• A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis
• Long-Term Complications of Appendectomy: A Systematic Review 
• Antibiotic therapy for acute appendicitis in adults. Fewer immediate complications than with surgery, but more subsequent failures
• Antibiotic Therapy for Appendicitis in Children
• Nonoperative vs Operative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-analysis | Emergency Medicine | JAMA Surgery

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