Appendix removal is the most common emergency surgery in children, but researchers say that antibiotics might offer a less-invasive alternative

Antibiotics could be an effective alternative to surgery for treating children with appendicitis, research suggests.

According to the NHS, appendicitis affects an estimated one in 13 people at some point in their life, with appendix removal the most common reason for emergency surgery in children.



But researchers say using antibiotics alone might offer a less invasive alternative – an approach that has already had some success in adult patients.

“It has become clear in recent years that in adults there are some patients with appendicitis who can recover from the disease without an operation, and we are frequently asked by parents of children with an appendicitis whether their child really needs an operation to get better,” said Nigel Hall, associate professor of paediatric surgery at the University of Southampton and co-author of the study.

While surgery remains the “gold standard” tried and tested treatment, often with some antibiotics, said Hall, “we are keen to explore the role of non-operative treatment for these children.”

Published in the journal Pediatrics by a team of scientists from the UK and Canada, the research involved a review of 10 existing studies published within the last decade. In total the studies involved 766 children from countries around the world – but not including the UK – of whom 413 were treated for uncomplicated, acute appendicitis with antibiotics alone rather than surgery.

Six of the studies compared the use of antibiotics alone with surgery, while the other four looked only at results for children treated with antibiotics. Different antibiotics and course durations were used in the studies, with both intravenous and oral regimes employed.



Overall, the authors found that the use of antibiotics alone was effective for 97% of children undergoing non-surgical treatment, while none of the studies reported any adverse effects of treating appendicitis with antibiotics.



However, appendicitis recurred in 14% of the children who did not have surgery. Overall, 82% of children who were treated with antibiotics alone avoided having surgery by the end of the various studies, a period that ranged from eight weeks to four years, depending on the research.

“While the benefit of non-operative treatment might be that you can avoid an operation, if you get a recurrence of your appendicitis it is likely that you will then be recommended to have an operation to remove the appendix in the long run,” said Hall. “So the benefit of avoiding an operation in the short term is gone.”

With only one of the ten studies considered in the review a randomised control trial, further rigorous research is needed to compare the effectiveness of antibiotics alone versus surgery for appendicitis, as well as to evaluate costs and quality of life for the different treatments.



“We really do need to do the prospective, comparative, randomised studies in order to be able to find out which is the better treatment option,” said Hall, adding that initial steps towards such studies are already underway in the UK by a team including Hall.

Furthermore, he noted, the review only covers simple, acute appendicitis and does not include children with complicated appendicitis, such as those with a perforated appendix or an appendix mass.



“We would very much not recommend that all children with appendicitis are treated with antibiotics and also very much that treatment of appendicitis remains a condition that needs to be treated by a specialist surgeon in a hospital,” said Hall.

Anthony Lander, a consultant surgeon at Birmingham Women’s and Children’s Hospital who was not involved in the study, acknowledged that both surgery and antibiotics alone have their benefits and drawbacks.

“Operations are expensive and have complications but there is no recurrent appendicitis. Antibiotics are cheap and very safe but may fail to treat the illness and surgery may still be required,” he said.

While Lander agreed with the need for large, rigorous studies to compare which approach might be best for treating early acute appendicitis, he added that the condition differs from person to person.



“A more valuable question would be “ What is the nature of the appendicitis which can be treated by antibiotics alone, safely and without a high recurrence rate?” and “Which cases should have an operation?”,” he said “The challenge is to design a study to answer this question.”.



John Abercrombie, a consultant colorectal surgeon and spokesperson for emergency general surgery at the Royal College of Surgeons, welcomed the study. “What this shows is quite similar to similar publications looking at appendicitis in adults where antibiotic treatments are being shown to be safe for selected cases,” he said.



“It is an important treatment option that needs to be discussed and for suitable children it seems like a very reasonable thing to do and may offer the chance to avoid an operation,” he added.