South Africa needs to reject the concept of antibiotics as the primary treatment of acute uncomplicated appendicitis.

Abstract

The movement in the high-income countries of the world away from surgery as the mainstay of treatment for acute uncomplicated appendicitis, has been well documented and is supported both in the literature and by several prominent surgical societies, in both North America and Europe.^1,2 The proponents of this approach point to the cost savings associated with reduced use of operating theatres and laparoscopic equipment, as well as the prevention of longterm morbidity such as port site hernias and abdominal adhesions.^1,2 They also point to the use of antibiotics as firstline therapy in other abdominal emergencies such as acute diverticulitis. In acute diverticulitis antibiotic therapy may abort acute low-grade inflammation and help avoid surgery, which traditionally involves a morbid stoma. The proponents of non-operative management of acute uncomplicated appendicitis point to the many benefits of this approach. The recent Comparison of Antibiotic Drugs and Appendectomy (CODA) trial which randomised 1 552 adult patients with acute uncomplicated appendicitis, to either laparoscopic appendicectomy or antibiotic therapy, concluded that antibiotics were non-inferior to appendectomy based on results of a standard health-status measure. It should be noted that in the antibiotics group, nearly 3 out of every 10 participants had subsequently undergone an appendectomy by 90 days. Also of note is that patients with an appendicolith were at a higher risk for delayed appendectomy and complications than those without an appendicolith.^1,2 The authors went on to state that in the antibiotics group, more than 7 in 10 participants avoided surgery, were treated mostly as outpatients and subsequently missed fewer days at work.