Use of Antibiotics for Appendicitis

Though operation appendectomy still Becomes standard management of acute appendicitis without complications, some meta-analysis show potency use antibiotics for treatment of appendicitis. [1–4]

 

fact, there are proof showing start that antibiotics could become choice therapy safe start for woman pregnant with appendicitis, but have limitations access fast to service surgery. [5]

 

On the other hand, there are questioning opinion effectiveness antibiotics compared appendectomy with reason level recurrence more symptoms of appendicitis high in patients who received antibiotics as therapy beginning precede operation.

 

Use of Antibiotics for Appendicitis

Besides that, there is worries that interval appendectomy or delay appendicitis surgery consequence therapy antibiotics potential cause fatal complications later day. A number of studies state recurrence appendicitis I During interval appendectomy is 6–37%, and surgical complications by 3-23%. [6]

 

because it is necessary conducted review proof scientific related benefit antibiotics as therapy early acute appendicitis, grade failure therapy antibiotics in overcome appendicitis, obstacles technical and opportunity therapy antibiotics before consider appendectomy in patients with acute appendicitis in Indonesia.

 

Antibiotics as Initial Treatment of Acute Appendicitis

A number of studies has learned potency benefit therapy or antibiotics compared appendectomy as therapy early in the patient with acute appendicitis without perforation.

 

Indicators that can be made as reference benefit antibiotics when compared with appendectomy, including proportion the last patient need appendectomy on the moon first and last year first post gift antibiotics, percentage incident major and minor complications, and cost total health imposed.

 

Meta - analysis involving 1116 patients of 5 clinical trials random find difference risk complications Among group patients who receive antibiotics compared operation as therapy early. Difference Major complications were 2.6% and minor complications were 7.2%. However, by statistics difference this no significant. [3]

 

Though thus, from meta-analysis seen risk more major and minor complications small on usage antibiotics compared appendectomy in therapy early non- perforated acute appendicitis. [3]

 

Temporary that, of the total patients who underwent therapy antibiotics at the beginning, as much as 8.2% at the end need action operation on month first post therapy, while around 22.6% experienced recurrence of appendicitis in 1 year period since initiation antibiotics. [3]

 

Similar results were also observed by meta-analysis previously revealed that 27.4% of patients who received therapy antibiotics, then experience recurrence symptoms of appendicitis and 96.7 % of patients with recurrence of appendicitis finally undergo operation appendectomy. [1]

 

Second meta - analysis above support proof that therapy antibiotics have potency as therapy early acute appendicitis without complications. Only approximately 10% of the total patients who received antibiotics need undergo appendectomy in period 30 days since gift therapy, while around one third patients who receive antibiotics will experience recurrence symptom in 12 months first. [1,3]

 

This thing need be delivered as part from education to patients, especially in patients who have trend for endure pain and need time longer in consider decision surgery in cases of acute appendicitis. [1,3]

 

Study recent also shows existence potency gift antibiotics in case of acute appendicitis for patient take care road. Clinical trial random multicenter in the United States find that gift antibiotics intravenous for 48 hours or more combined with oral antibiotics for 8 days cause repair symptoms in the majority patients, namely 93.3%. [7]

 

Similar with results study before, in period time act carry on for 12 months post therapy antibiotics, it was found that 2 of 15 participants (13.3%) experienced recurrence symptoms of appendicitis. [1,3]

 

Although study this hint existence opportunity uses antibiotics as treatment early acute appendicitis without complications in scenario take care road, still there is a number of limitations. Limitations studies the covers amount minimal sample, still prioritize modality radiology level carry on such as CT-Scan in the diagnosis of appendicitis, and collect patient from the emergency room possible emergency different characteristics with condition take care walk in other units. [1,3,7]

 

Another clinical trial includes patient children with acute appendicitis without perforation get interesting results. One child in the group patients who receive antibiotics no show repair symptoms, so undergo operation appendectomy on the day second therapy, top parent request. However, the findings moment operation shows appearance appendix normal patient and outcome histopathology non- inflammatory appendix.

 

Besides that, in period time monitoring for 12 months, 6 children in the group who received antibiotics finally undergo appendectomy related recurrence symptom painful stomach or parent request. Inspection advanced conclude that no there is from six participant that has proof presence of appendicitis histopathology [4].

 

This thing indicates that in the population children, opportunity happening appendectomy negative need Becomes attention possible special troublesome moment to do education about gift antibiotics as therapy early in child with acute appendicitis.

 

Another meta-analysis was carried out for see comparison therapy antibiotics and appendectomy in children with appendicitis without complications. Use resolution symptom in 48 hours without appendectomy nor recurrence in 1 month post initiation antibiotics as criteria success therapy, study this find that gift antibiotics have level enough success height, that is reached 90.5%.

 

Analysis advanced show that there is enhancement risk failure therapy antibiotics by 10.43% in patients child with acute appendicitis who have findings appendicolith on examination radiology. Besides In that, there were 26.8% of participants who experienced recurrence symptoms of appendicitis in period 1 year time since initiation therapy antibiotics. [8]

 

Potential and Technical Constraints of Use Antibiotics for Acute Appendicitis in Indonesia

Various studies that have discussed above show a number of potencies use antibiotics as well as problems related to handling cases of acute appendicitis in Indonesia. Access transportation to center service health base nor level advanced difficult and levels relative poverty in rural areas taller compared urban Becomes challenge for patients who need home care sick or action surgery associated with appendicitis.

 

In Thing this, gift antibiotics before consider surgery for acute appendicitis considered as alternative relevant to the scenario clinical disease is in a remote area.

 

Potency Use Antibiotics for Acute Appendicitis in Indonesia

At least there is three reasons why use antibiotics have potency as step treatment early in cases of acute appendicitis without complications.

 

First, giving antibiotics chance lower risk major and minor complications of acute appendicitis. Complications in question in Thing this especially related with action surgery that alone like infection wound surgery, sepsis, up to perforation appendix. [3]

 

Second, antibiotics have level enough success tall in trigger resolution symptoms of acute appendicitis in the majority patients, reaching 90–92%. In context practice primary service in the area remote in Indonesia, p this allow doctor for make an initial diagnosis and treat case of acute appendicitis without complications with use antibiotics then plan appropriate reference to house sick who have service surgery. [1,8]

 

Third, handling beginning case of acute non- perforated appendicitis with antibiotics, compared action surgery, potentially lower cost related total health with appendicitis. Studies show that action operation related with enhancement cost total health by 60% compared therapy antibiotics in cases of acute appendicitis. [9]

 

Though Thus, potential this need studied more carry on through a clinical trial random multicenter on various area remote areas in Indonesia combined with analysis impact economy related different therapeutic regimens beginning, that is Among antibiotics or surgery, in cases of appendicitis.

 

Technical Obstacles of Use Antibiotics in Acute Appendicitis in Indonesia

Not could denied that there is constraint possible technical faced in prepare use program antibiotics as line first acute appendicitis therapy without complications. First, some big study that studies effectiveness therapy antibiotics in acute appendicitis use criteria combined clinical with criteria radiology based on abdominal CT Scan. [1,3,8]

 

The use of CT Scan is indeed could help with diagnosis, especially in filter case complex like abscess appendix and identify appendicolith, however inspection radiology level carry on sort of that no available wide in area remote in Indonesia.

 

Not rarely experts at - home surgeon sick isolated only depend on experience clinical in make decision clinical related step treatment of acute appendicitis. Besides In addition, the use of CT Scan is also necessary consider risk exposure high radiation. Use criteria clinical, such as Alvarado's low score and temperature body afebrile, can help predict patients who have possibility taller for get therapy with antibiotics. [7,10]

 

Second, there are variation protocol gift antibiotics in existing clinical trials. This thing difficult for made guidelines base election antibiotics in acute appendicitis without complications for patients in the area secluded in general depending on schema National Health Insurance. [10]

 

On schema this, part antibiotics no allowed use without there is sensitivity test evidence antibiotics, for example ceftazidime or meropenem, although sensitivity testing antibiotics alone no is guidelines standard use in many other countries. Study beginning required for determine an effective antibiotic regimen in accordance pattern sensitivity regional and local germs. [10]

 

Third, some big review systematic about benefit antibiotics in acute appendicitis only involve duration monitoring post relative therapy short so that effect period long antibiotics in reduce level recurrence still not yet known. [1,3]

 

Studies conclude that there are 60–70% rate success antibiotics in therapy early acute appendicitis without complications and only 15% of patients are at risk experience recurrence period long post initiation therapy. That is, under ideal conditions, monitoring patients who receive antibiotics for acute appendicitis must schedule by periodically for 5–10 year period after declared experience remission symptoms of appendicitis. [12]

 

Fourth, the use of antibiotics needs good communication and education to patients related risk enough recurrence height, that is about 25%, as well as conditions in which the patient need quick check self-return to service health. This thing will difficult in conditions were access to service health hard, ok consequence long distance nor limitations cost. [1,3,8]

 

Conclusion

Study show non- surgical treatment use antibiotics just could Become choice in acute appendicitis without complications. However, its use need consider level education patients and access to service health. Patients who are able understand about risk recurrence as well as have access to service good health could considered for use choice handling this.

 

Besides studies about appendectomy and therapy antibiotics in appendicitis, there are also studies that have compare effectiveness antibiotics monotherapy and polytherapy for children postoperative perforated appendicitis.

 

Sources:

1.     Harnoss JC, Zelienka I, Probst P, Grummich K, Müller-Lantzsch C, Harnoss JM, et al. Antibiotics Versus Surgical Therapy for Uncomplicated Appendicitis: Systematic Review and Meta-analysis of Controlled Trials (PROSPERO 2015:CRD42015016882). Ann Surg. 2017;265(5):889–900.

2.     Kessler U, Mosbahi S, Walker B, Hau EM, Cotton M, Peiry B, et al. Conservative treatment versus surgery for uncomplicated appendicitis in children: A systematic review and meta-analysis. Arch Dis Child. 2017;102(12):1118–24.

3.     Sallinen V, Akl EA, You JJ, Agarwal A, Shoucair S, Vandvik PO, et al. Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Mr J Surg. 2016;103(6):656–67.

4.     Svensson JF, Patkova B, Almström M, Naji H, Hall NJ, Eaton S, et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children. Ann Surg. 2015;261(1):67–71.

5.     Jensen TD, Penninga L. Appendicitis during pregnancy in a Greenlandic Inuit woman; antibiotic treatment as a bridge-to-surgery in a remote area. BMJ Case Rep. 2016;2016.

6.     Hori T, Machimoto T, Kadokawa Y, Hata T, Ito T, Kato S, et al. Laparoscopic appendectomy for acute appendicitis: how to discourage surgeons using inadequate therapy. World J Gastroenterol. 2017;23:5849–59.

7.     Talan DA, Krishnadasan A, Amii R, Pathmarajah K, Morim A, Moran GJ, et al. Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management. Ann Emerg Med. 2017;70(1):1–11.e9.

8.     Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z. Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children a meta-analysis. JAMA Pediatrics. 2017;171(5):426–34.

9.     Sippola S, Grönroos J, Tuominen R, Paajanen H, Rautio T, Nordström P, et al. Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Mr J Surg. 2017;104(10):1355–61.

10. Loftus TJ, Brakenridge SC, Croft CA, Stephen Smith R, Efron PA, Moore FA, et al. Successful nonoperative management of uncomplicated appendicitis: predictors and outcomes. J Surg Res. 2018;222:212–218.e2. https://doi.org/10.1016/j.jss.2017.10.006

11. Ministry of Health. 2013 National Formulary ;53(9):1689–99.

12. Lundholm K, Hansson- Assarsson J, Engström C, Iresjö BM. Long-Term Results Following Antibiotic Treatment of Acute Appendicitis in Adults. World J Surg. 2017;41(9):2245–50. http://link.springer.com/10.1007/s00268-017-3987-6