Written by Vivian Lei
Antibiotic treatment for acute uncomplicated appendicitis in children has a significantly higher failure rate (34% vs. 7%) compared to appendectomy, but this is limited by differing definitions of failure and the chosen non-inferiority margin.
Antibiotics buy time, but surgery seals the deal
This is a large, international, multicenter, randomized, non-inferiority trial comparing antibiotic therapy to appendectomy for the treatment of acute uncomplicated appendicitis in children aged 5 to 16 years. Conducted across 11 pediatric hospitals in Canada, the USA, Finland, Sweden, and Singapore, the trial aimed to assess whether antibiotics were non-inferior to surgery based on treatment failure rates at one year. A total of 936 patients were randomized to either appendectomy (n=459) or antibiotic treatment (n=477). In the antibiotic group, failure was defined as need for appendectomy, while in the appendectomy group, it was defined as a normal appendix on pathology or surgical complication.
At one year, treatment failure occurred in 34% of the antibiotic group versus 7% in the surgical group (difference 26.7%, 90%CI 22.4–30.9). Since the upper bound exceeded the previously defined 20% non-inferiority margin, antibiotics were deemed inferior.
Patients in the antibiotic group had a longer total hospital stay but experienced a faster return to normal activities and required fewer pain medications. No serious adverse events or deaths were reported in either group. While antibiotic therapy avoided initial surgery in many cases, the recurrence rate and need for appendectomy in nearly one-third of patients suggest that appendectomy remains the definitive treatment for uncomplicated appendicitis in children.
How will this change my practice?
While appendectomy is undeniably the most definitive treatment for acute appendicitis, the trial’s design complicates the interpretation of comparative failure rates due to differing definitions of failure between treatment groups. A notable takeaway from this study is that two-thirds of children in this study successfully avoided surgery for one year with antibiotic-only treatment. Although the data clearly favor appendectomy for uncomplicated appendicitis, I think patient/family preference and the potential benefits of non-surgical management should still be considered in select cases.
Source
Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial. Lancet. 2025 Jan 18;405(10474):233-240. doi: 10.1016/S0140-6736(24)02420-6. Erratum in: Lancet. 2025 Feb 8;405(10477):468. doi: 10.1016/S0140-6736(25)00206-5. PMID: 39826968
