May 20, 2022

Antibiotics are less effective in children with more appendicitis pain

Children who have greater acute appendicitis pain may be less likely to improve if treated with antibiotics alone, according to a secondary analysis of a non-randomized clinical trial.


Dr. Rebecca Rentea

“While approximately 35% of families chose nonoperative management, a high pain score between 7 and 10 on a 10-point scale almost doubled treatment failure in hospital,” said Rebecca Mr. Rentea, MD, pediatric surgeon and director of the Comprehensive Colorectal Center at Children’s Mercy Kansas City, Missouri, said Medscape Medical News in an email.

“Even if the non-operative management of pediatric appendicitis didn’t work – resulting in the need to remove the appendix in 34% of cases – families were happy with their decisions 1 year later,” added Rentea, co-author of a guest comment about the study.

Study lead author Peter C. Minneci, MD, MHSc, a pediatric surgeon at Nationwide Children’s Hospital, Columbus, Ohio, and colleagues analyzed a subset of patients from a larger study at 10 tertiary hospitals for children from the Midwest Pediatric Surgery Consortium.

As they reported in Open JAMA Networkthe larger prospective, non-randomized clinical trial enrolled 1068 children between 2015 and 2018. The children were 7 to 17 years old and they had imaging-confirmed appendicitis with an appendix diameter of 1.1 cm or less, no abscess, no appendicolitis and no phlegmon. The white blood cell count was between 5,000 and 18,000 cells/μL and abdominal pain started less than 48 hours before antibiotic treatment.

Caregivers chose either surgery or non-operative antibiotic management. Patients who were treated first with antibiotics alone and who did not undergo appendectomy less than one year were considered to have successfully completed nonoperative treatment.

The secondary analysis included the 370 children enrolled in the nonoperative group. Among them, 229 were boys and the median age was 12.3 years. In this subgroup, researchers compared outcomes after nonoperative antibiotic management versus surgery.

At 1 year, a treatment failure had occurred in 125 patients, 53 of whom had undergone an appendectomy during their first hospitalization and 72 had had a late treatment failure after their discharge.

  • Higher patient-reported pain at presentation was linked to a higher risk of treatment failure in hospital (relative risk [RR], 2.1; 95% CI, 1.0, 4.4) but not for delayed treatment failure (RR, 1.3; 95% CI, 0.7, 2.3) or overall treatment failure at 1 year (RR, 1.5; 95% CI, 1.0, 2.2).

  • Pain lasting more than 24 hours was associated with a lower risk of delayed treatment failure (RR, 0.3; 95% CI, 0.1, 1.0) but not treatment failure at hospital (RR, 1.2; 95% CI, 0.5 – 2.7) or treatment failure at 1 year (RR, 0.7; 95% CI, 0.4 – 1.2).

  • Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 versus 27.0; difference, 1.0; 95% CI, 0.01, 2.0 ) and at 1 year (28.1 versus 27.0; difference, 1.1; 95% CI, 0.2-2.0).

Researchers found no increased risk of treatment failure based on age, gender, race, ethnicity, white blood cell count, primary language, insurance status , transfer status, presenting symptoms or imaging findings.

Antibiotics alone are a safe option for children

“This study suggests that pediatric patients with acute appendicitis should be offered treatment options, including nonoperative management,” the authors write. “Treatment with antibiotics alone is a safe and equitable option for children, with no increased risk of treatment failure based on objective sociodemographic or clinical characteristics at the time of presentation.

But, advise the authors: “Families should be informed that treatment failure is not uncommon, and they should be provided with anticipatory advice on how to proceed if symptoms reappear.”

The investigators acknowledged the limitations of the study, including the non-randomized design which may have introduced bias, the loss to follow-up, and the study population being children from the U.S. Midwest, which may differ from children elsewhere in the country.



Dr Shawn St Peter

Shawn D. St Peter, MD, pediatric surgeon, medical director and senior vice president of Children’s Mercy Kansas City, told Medscape in an email that it’s important to have a nonoperative alternative to surgical appendectomy. .

“Antibiotics are the initial treatment for appendicitis and may be the definitive treatment,” he said.

“Surprisingly, no sociodemographic or clinical characteristics were associated with an increased risk of treatment failure for nonoperative appendicitis,” added St Peter, co-author of the commentary with Rentea.

Howard C. Jen, MD, a pediatric surgeon at UCLA Mattel Children’s Hospital in Los Angeles, Calif., wasn’t surprised by the results.



Dr. Howard Jen

“Non-operative management of uncomplicated acute conditions appendicitis in children continues to be safe and effective in highly selected patients,” he said in an email. “This alternative to surgery should be routinely offered to patients with early acute appendicitis.”

Jen, who was not involved in the current study, noted that it did not address the impact and costs to families of nonoperative management versus surgery.

“For the most vulnerable children who have had difficulty accessing medical care, what is the best treatment option? What factors are important to families when making this decision?” He asked.

Not all study and editorial authors report any relevant financial relationships. The study was funded by the Patient-Centered Outcomes Research Institute and the National Center for Advancing Translational Sciences.

Open JAMA Network. Published online May 2, 2022. Full Text, Editorial