Treating Appendicitis With Antibiotics

Your appendix — a small pouch connected to your large intestine — can become inflamed and filled with bacteria and pus, resulting in a painful condition called appendicitis. If appendicitis isn’t treated promptly, your infected appendix will rupture, releasing its bacteria into the rest of your abdomen and leading to a potentially life-threatening infection.

Surgery to Treat Appendicitis: Appendectomy

Appendectomy, a surgical procedure to remove the appendix, is the standard treatment for appendicitis. But antibiotics are often used in conjunction with an appendectomy and sometimes instead of the surgery if the case is uncomplicated.

Doctors have been treating appendicitis with appendectomies for more than 100 years. (1)

If you undergo either an open or laparoscopic appendectomy, you can expect to leave the hospital one or two days after surgery (an open appendectomy requires one 2- to 4-inch incision, while a laparoscopic appendectomy requires three small incisions). Some laparoscopic appendectomies are even performed on an outpatient basis. (2) Full recovery is relatively quick (several weeks), and few postoperative complications occur. Most patients don’t need to make lifestyle or diet changes after the operation. (3)

Before conducting an appendectomy, surgeons usually give their patients broad-spectrum antibiotics, which work against a wide range of bacteria. (4)

Antibiotics Used for Treating Appendicitis

The antibiotics used for appendicitis include:

  • cefotetan (Cefotan)
  • cefotaxime (Claforan)
  • piperacillin and tazobactam (Zosyn)
  • ampicillin and sulbactam (Unasyn)
  • ceftriaxone (Rocephin)
  • cefepime (Maxipime)
  • gentamicin (Garamycin)
  • meropenem (Merrem)
  • ertapenem (Invanz)
  • metronidazole (Flagyl)
  • clindamycin (Cleocin)
  • levofloxacin (Levaquin)

In the case of a ruptured appendix, doctors will prescribe an intravenous (IV) antibiotic to treat abdominal infection — such as peritonitis, a serious infection of the peritoneum membrane that lines your abdominal cavity — after removing your appendix.

Your doctor may decide to follow that up with several weeks of an oral antibiotic that you take at home, but research suggests that three to five days of IV antibiotics are enough. (4)

Doctors often opt for a so-called interval appendectomy if a patient has a ruptured appendix. In this case, you will be treated with several days of IV antibiotics and then may be sent home with an oral antibiotic. Some research has suggested that IV treatment alone in the hospital is sufficient. After an interval of six to eight weeks, if your infection has cleared up, you will undergo an appendectomy.

Are Antibiotics Alone Enough for Appendicitis?

In recent years, some research has suggested that appendectomies aren’t necessary to treat uncomplicated appendicitis, which is appendicitis without a ruptured appendix, pus-filled abscesses, or peritonitis. Instead, an antibiotic-only treatment can do the trick. In clinical trials, patients with uncomplicated appendicitis who were treated only with antibiotics required fewer doses of narcotics, returned to work quicker, and did not have a higher perforation rate than those who underwent an immediate appendectomy. (5)

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Although there’s increasing evidence to support this approach in uncomplicated appendicitis, there are nevertheless concerns. Uncomplicated appendicitis can be hard to reliably distinguish from complicated appendicitis, and sometimes the complexity of a case isn’t determined until the time of surgery. (5) And as the American College of Surgeons notes, there’s a higher chance of recurrence with antibiotic-only treatment. (6)

Up to 63 percent of patients who receive antibiotic-only treatment for acute uncomplicated appendicitis, which comes on quickly, need no additional treatment for at least a year, according to a 2012 study that did an analysis of four controlled trials involving 900 patients. Additionally, antibiotic-only treatment is cheaper than surgery and results in 31 percent fewer complications (though appendectomies already have low complication rates), according to the study. (7)

A 2015 report also found that an “antibiotics first” option may be useful for people who have had complications from prior surgery. However, the report also found that “as many as half the patients so treated will have early treatment failures, and all have a risk of recurrent appendicitis that may ultimately require appendectomy.” (8)

Additionally, the 2012 study noted that about 20 percent of patients who received antibiotic-only treatment suffered from appendicitis again within a year; and 20 percent of those people required treatment for a ruptured appendix and the associated complications on their recurrent appendicitis case. (7)

A separate study from 2015 found a similar failure rate of antibiotic treatment. In patients with uncomplicated appendicitis (as proved by a CT scan), 27 percent required surgical intervention within a year. Still, most patients receiving antibiotic treatment did not require an appendectomy during the one-year follow-up period, and those who required an appendectomy did not experience significant complications. (9)

Against that backdrop, a 2017 review of studies considered whether nonoperative treatment should replace appendectomy as the first-line treatment based on an analysis of the current evidence. The researchers determined that while nonoperative treatment is “definitely a feasible and effective alternative for uncomplicated appendicitis,” appendectomy remains the “gold standard of treatment” for uncomplicated appendicitis due to its higher rate of treatment efficacy. (10)

Additional reporting by Deborah Shapiro

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