Antibiotic therapy remains a durable and safe alternative to surgery for selected adults with uncomplicated acute appendicitis, with fewer overall complications and comparable quality of life, according to the 10-year observational follow-up of patients in the Appendicitis Acuta (APPAC) trial.
The analysis represented a prespecified long-term observational follow-up of a multicentre, open-label randomised clinical trial conducted at six Finnish hospitals between 2009 and 2012. It aimed to determine the 10-year appendicitis recurrence and appendectomy rates among adults with uncomplicated acute appendicitis initially treated with antibiotics.
The original trial enrolled 530 adults aged 18–60 years with computed tomography-confirmed uncomplicated acute appendicitis. Participants were randomly assigned to open appendectomy (n=273) or antibiotic therapy (n=257).
Antibiotic treatment consisted of three days of intravenous ertapenem followed by seven days of oral levofloxacin and metronidazole. The final follow-up date for the analysis was 29 April 2024.
Antibiotics and recurrence in appendicitis
At 10 years, 253 of 257 patients with uncomplicated appendicitis who had been (98.4%) allocated to antibiotics were assessed for recurrence. The true appendicitis recurrence rate, defined by histopathological confirmation, was 37.8% (95% CI, 31.6–44.1%).
The cumulative appendectomy rate in the antibiotic group was 44.3% (95% CI, 38.2–50.4%), with most recurrences and subsequent operations occurring within the first two years. More than half of patients initially treated with antibiotics avoided surgery over the decade of follow-up.
The overall 10-year cumulative complication rate was significantly lower in the antibiotic group than in the appendectomy group (8.5% vs 27.4%; P<0.001).
Quality-of-life outcomes, assessed using the validated European QOL-5 Dimensions questionnaire, did not differ significantly between treatment groups, and median health index values were identical.
Addressing study limitations
The authors noted several limitations including protocol-mandated appendectomy for suspected appendicitis recurrence, which may have increased surgery rates; incomplete magnetic resonance imaging follow-up among patients with an intact appendix; and the use of open rather than laparoscopic surgery, reflecting the trial period.
As such, they recommended that future studies should focus on the optimisation of non-operative management in outpatient settings, which could involve solely symptomatic treatment and mean that many patients could be safely discharged from the emergency department without the need for admission.
The authors also noted the use of broad-spectrum antibiotics as a limitation but added that the ongoing APPAC IV randomised, double-blind clinical trial aims to address this by comparing oral moxifloxacin and placebo for uncomplicated acute appendicitis in an outpatient setting.
Overall, the findings supported antibiotics as a viable treatment option for uncomplicated acute appendicitis in adults, the authors concluded.
Reference
Salminen P et al. Antibiotic Therapy for Uncomplicated Acute Appendicitis: Ten-Year Follow-Up of the APPAC Randomized Clinical Trial. JAMA 2026; Jan 21: doi:10.1001/jama.2025.25921 [online ahead of print].
This article was originally published by our sister publication Hospital Healthcare Europe.
