Written by Joshua Belfer
Spoon Feed
Antibiotic-only management of uncomplicated pediatric appendicitis led to nearly five times higher failure rates and more major complications within a year compared with appendectomy, suggesting the knife still has the edge.
A non-operative option, but not a non-issue
Nonoperative management (NOM) for acute uncomplicated appendicitis has been an appealing idea––skip surgery, give antibiotics, avoid scars. Earlier studies hinted it could work, but evidence was patchy. This updated systematic review and meta-analysis pooled 7 RCTs (n = 1,480) comparing antibiotics vs. appendectomy in children. At 1 year, treatment failure was 36.6% with NOM vs. 7.0% with surgery (RR 4.97, 95%CI 3.57-6.91). Treatment success favored surgery (94% vs 65%). Severe complications were markedly higher with NOM (RR 33.4, 95%CI 7.9-141). Children in the NOM group did return to school around 1.4 days sooner and to normal activities about 5 days sooner, but that small early benefit may be offset by later readmissions and repeat operations.
As always, the caveats matter. Studies differed in definitions of success, diagnostic imaging, and follow-up; nearly half lacked long-term quality-of-life data. Still, heterogeneity for primary outcomes was minimal, and only randomized trials were included, raising confidence that this isn’t just noise.
How will this change my practice?
In my experience, most families accept that “appendicitis means surgery,” but sometimes the question arises: Is the operation really necessary? The best evidence suggests that, for long-term success and fewer complications, appendectomy remains the more reliable option.
That said, as the authors note, “both NOM and appendectomy are valid treatment options… [and should be] discussed in a patient-centered, individualized fashion.” There will always be select scenarios where antibiotics make sense––say, a competitive athlete eager to return to play or a family facing imminent travel. The key is making sure families understand the trade-offs. While nonoperative management may buy time in the short term, surgery still offers the best odds for lasting recovery.
Source
Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis: A Systematic Review and Meta-Analysis. JAMA Pediatr. 2025 Oct 5:e254091. doi: 10.1001/jamapediatrics.2025.4091. Epub ahead of print. PMID: 41046476; PMCID: PMC12498239.
I am unable to review the article presumable due to an embargo. That said, if all the patients had a CT scan and a fecolith is detected, I doubt antibiotics alone would effectively resolve the appendicitis. If only inflammation and swelling of the mucosal tissue are present, I would think that antibiotic only therapy would have a greater chance of resolution.