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Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2156 (Published 05 April 2012) Cite this as: BMJ 2012;344:e2156

Re: Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

This article is an attempt to look into role of nonoperative management of appendicitis based on statistical analysis of available evidence from published 4 randomised trials. It is uncertain whether it will make real change in current practice of individual surgeons.

We all know that majority of appendicitis cases will not lead to serious complications. But it is to avoid the serious complication of perforation in widely believed 20% cases ( 8% in this study), that appendicectomy is considered gold standard.

The main argument in this study in favour of antibiotic use is 39% reduction in complication rate of perforation, peritonitis and wound infection in antibiotic group compared to appendicectomy group. Wound infection is unique to appendicectomy group and is usually minor. If we remove this from the list of complications, is there still risk reduction in terms of complications?

One in twentyfive patients in antibiotic treated group and discharged home returned back with perforation in this study.

The authors accept that study had problem in analysing non- heterogenous data and there was no uniform antibiotic policy.

I fully appreciate the need to avoid unnecessary appendicectomies. But current practice in UK still uses clinical judgement in diagnosis of the condition. I doubt that there is uniformity in radiologists across the NHS in terms of providing reports with high diagnostic value based on imaging.

Also a standardised regiment of antibiotic protocol will have to be in place, considering risk of antibiotic resistance. At the moment most hospitals have separate and differing protocols for antibiotic regimens for clinical conditions.

I think, unless the above mentioned issues are not settled, a dramatic shift in management of these cases is unlikely.

Competing interests: No competing interests

13 April 2012
Krishna P Gupta
General Surgeon
Blackpool Victoria Hospital
Whinney Heys Road, Blackpool, FY3 7LT
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