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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: (Published 05 April 2012) Cite this as: BMJ 2012;344:e2156
  1. Krishna K Varadhan, research fellow1,
  2. Keith R Neal, professor12,
  3. Dileep N Lobo, professor1
  1. 1Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen’s Medical Centre, Nottingham NG7 2UH, UK
  2. 2Department of Epidemiology and Public Health, Nottingham University Hospitals
  1. Correspondence to: D N Lobo Dileep.Lobo{at}
  • Accepted 23 February 2012


Objective To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis.

Design Meta-analysis of randomised controlled trials.

Population Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations.

Interventions Antibiotic treatment versus appendicectomy.

Outcome measures The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions.

Results Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I2=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I2=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis.

Conclusion Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.


  • This paper was presented at the annual scientific meeting of the Society of Academic and Research Surgery in Nottingham, UK, in January 2012. An abstract will be published in the British Journal of Surgery.

  • Contributors: All three authors contributed to the conception and design of the study, to analysis and interpretation of data, to drafting the article and revising it critically for important intellectual content, and to final approval of the version to be published. DNL is the guarantor.

  • Funding: KKV was funded by a research fellowship from the Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit. The funders had no role in the design, execution, and writing up of the study.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not needed.

  • Data sharing: No additional data available.

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