Written by Megan Hilbert
Spoon Feed
In acute uncomplicated appendicitis treated with antibiotics, the recurrence rate was 37.8% and appendectomy rate was 44.3% at 10-year follow up.
Take this conclusion with a grain of salt (or a bevy of antibiotics)
This was a planned secondary analysis of the APPAC trial—a multicenter, open-label, randomized, noninferiority clinical trial for patients with CT-confirmed uncomplicated appendicitis. It was originally randomized into open appendectomy* versus antibiotic treatment (3d of IV ertapenem followed by 7d of oral levofloxacin and metronidazole**). The primary endpoint was success of treatment at 1 year. This predefined secondary analysis evaluated recurrence of appendicitis and appendectomy rate, as well as post-intervention complication rate, at 10 years. Prior studies have only evaluated 5 years after initial presentation.
True appendicitis recurrence rate was 37.8% (87/230) of those initially treated with antibiotics. Appendectomy rate was 44.3% in this same group at 10-year follow up. The vast majority of recurrences (65/87; 74.7%) and appendectomies (8/112; 77.7%) occurred within 2 years of initial presentation. Overall complication rate at 10 years for the appendectomy group was 27.4% (95%CI 21.6%–33.3%) and 8.5% (95%CI 4.8%–12.1) in the antibiotic group (p<0.001).
The authors thus concluded that initial antibiotic management was durable and not only reasonable, but safe in the treatment of this etiology.
I will give the authors credit: for those who did not undergo appendectomy, they were offered MRI at the 10-year mark to ensure that they were not missing an appendiceal tumor. While overall prevalence was low at 1.2% (95%CI 0.3%-2.2%), I applaud them for ensuring the safety of these patients.
*Who is doing open appendectomy as standard of care?!
**Not your run-of-the-mill “treat and street” antibiotic regimen.
How will this change my practice?
When I was originally reading this paper, I was excited. It seemed like I could conclude that initial antibiotic treatment for acute uncomplicated appendicitis was reasonable and did not often result in recurrence. While that is true, upon thinking more critically, I feel slightly let down. From the ER, I don’t intend to admit every acute uncomplicated appendicitis for three days of IV antibiotics… it just isn’t feasible. So while I applaud the authors for doing this secondary analysis, I don’t know that it resulted in any actionable information for me.
Editor’s note: Over 40% of the time, patients must return for more imaging and surgery… that doesn’t sound like a rousing success to me. ~Clay Smith
Source
Antibiotic Therapy for Uncomplicated Acute Appendicitis: Ten-Year Follow-Up of the APPAC Randomized Clinical Trial. JAMA. 2026 Jan 21:e2525921. doi: 10.1001/jama.2025.25921. Epub ahead of print. PMID: 41563747; PMCID: PMC12824850.
