Nationwide Children’s Hospital study: Antibiotics alone can be an effective treatment for children with appendicitis

20 Dec

The National Institute of Diabetes and Digestive and Kidney Diseases provide facts about appendicitis:

Definition and Facts for Appendicitis

What is appendicitis?

Appendicitis is inflammation of your appendix.

How common is appendicitis?

In the United States, appendicitis is the most common cause of acute abdominal pain requiring surgery. Over 5% of the population develops appendicitis at some point.1

Who is more likely to develop appendicitis?

Appendicitis most commonly occurs in the teens and twenties but may occur at any age.1

What are the complications of appendicitis?

If appendicitis is not treated, it may lead to complications. The complications of a ruptured appendix are

  • peritonitis, which can be a dangerous condition. Peritonitis happens if your appendix bursts and infection spreads in your abdomen. If you have peritonitis, you may be very ill and have
    • ​​​​fever
    • nausea
    • severe tenderness in your abdomen
    • vomiting
  • ​an abscess of the appendix called an appendiceal abscess.​

1 Acute Abdomen and Surgical Gastroenterology. The Merk Manual website. http://www.merckmanuals.com/professional/gastrointestinal_disorders/acute_abdomen_and_surgical_gastroenterology/appendicitis.htmlExternal Link Disclaimer. Updated June, 2014. Assessed October 2014.                                 http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/appendicitis/Pages/definition-facts.aspx

Appendicitis can be a serious illness because of the complications.

Seattle Children’s Hospital describes appendicitis symptoms:

Symptoms of Appendicitis

It’s important to know the symptoms of appendicitis so you can get help quickly.

For children 2 years old and younger, the most common signs of appendicitis are pain in the lower belly, vomiting and swelling in the belly. An older child may first complain of pain near the belly button. Over time, the pain moves to the lower-right belly. In most cases, the pain doesn’t get better even if the child lies still. Movement usually makes the pain worse.

Your child may also have these symptoms:

  • Not wanting to eat
  • Feeling sick to their stomach
  • Vomiting
  • Diarrhea
  • Low-grade fever
  • Swollen or bloated belly

If the appendix bursts, your child may get a high fever because of the spreading infection.

If you think your child may have appendicitis, call your doctor or bring your child to our Emergency Department right away. Don’t give your child anything to eat or drink, including medicine for pain, unless your doctor tells you to. Appendicitis treatment usually includes surgery to remove the appendix.

Appendicitis Diagnosis

It can be hard to tell if appendicitis is the reason a child’s belly hurts. The doctor will ask for a detailed history of your child’s illness and examine your child’s belly, looking for tender spots. We might use a blood test or urine test — or take images of the inside of your child’s abdomen — to make sure we know exactly what is causing the symptoms.

We can often diagnose appendicitis using ultrasound. This saves children from being exposed to the radiation that goes along with X-rays or CT (computed tomography) scans.                                 http://www.seattlechildrens.org/medical-conditions/digestive-gastrointestinal-conditions/appendicitis-symptoms/

A Nationwide Children’s Hospital study concludes antibiotics alone can be an effective treatment for children with appendicitis.

Science Daily reported in Antibiotics alone can be a safe, effective treatment for children with appendicitis:

Using antibiotics alone to treat children with uncomplicated acute appendicitis is a reasonable alternative to surgery when chosen by the family. A study led by researchers at Nationwide Children’s Hospital found that three out of four children with uncomplicated appendicitis have been successfully treated with antibiotics alone at one year follow-up. Compared to urgent appendectomy, non-operative management was associated with less recovery time, lower health costs and no difference in the rate of complications at one year.

“Families who choose to treat their child’s appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn’t work, have expressed that for them it was worth it to try antibiotics to avoid surgery,” said Peter C. Minneci, MD who led the study published online Dec. 16 in JAMA Surgery with Katherine J. Deans, MD. The pair are co-directors of the Center for Surgical Outcomes Research and principal investigators in the Center for Innovation in Pediatric Practice in The Research Institute at Nationwide Children’s. “These patients avoided the risks of surgery and anesthesia, and they quickly went back to their activities.”

“Surgery has long been the ‘gold standard’ of care for treating appendicitis because by removing the appendix we eliminate the chance that the appendicitis will ever come back,” said Dr. Deans. “However, early in our careers we noticed that patients with appendicitis who were placed on antibiotics overnight until their surgery the following morning felt better the next day. So, Pete and I asked ourselves: do they really need to have surgery?”

In the first study conducted and published in the United States examining non-operative management for appendicitis, they enrolled 102 patients age 7 to 17 who were diagnosed with uncomplicated acute appendicitis at Nationwide Children’s between October 2012 and October 2013. Participants had early/mild appendicitis, meaning that they experienced abdominal pain for no more than 48 hours; had a white blood cell count below 18,000; underwent an ultrasound or CT scan to rule out rupture and to verify that their appendix was 1.1 centimeter thick or smaller; and had no evidence of an abscess or fecalith, which is hard stone-like piece of stool.

Thirty-seven families chose antibiotics alone and 65 opted for surgery. Those patients in the non-operative group were admitted to the hospital and received IV antibiotics for at least 24 hours, followed by oral antibiotics after discharge for a total of 10 days. Among those patients, 95% showed improvement within 24 hours and were discharged without undergoing surgery. Rates of appendicitis-related medical care within 30 days were similar between the groups with two patients in the non-operative group readmitted within 30 days for an appendectomy. At one year after discharge, three out of four patients in the non-operative group did not have appendicitis again and have not undergone surgery.

Appendicitis, caused by a bacterial infection in the appendix, is the most common reason for emergency abdominal surgery in children, sending more than 70,000 young people to the operating room each year. Although many of these cases are severe and require surgery, there are a good number that would be candidates for treatment with antibiotics alone, Dr. Minneci said…

According to the study results, patients who were transferred to Nationwide Children’s from other institutions expressed concerns about the distance and time necessary to come back if the appendicitis recurred. These families opted for surgery more often. Patients whose families spoke primary languages other than English were more likely to choose antibiotics as a course of treatment due to cultural values to avoid surgery if at all possible….

http://www.sciencedaily.com/releases/2015/12/151216134409.htm

Citation:

Antibiotics alone can be a safe, effective treatment for children with appendicitis

Date:      December 16, 2015

Source: Nationwide Children’s Hospital

Summary:

Using antibiotics alone to treat children with uncomplicated acute appendicitis is a reasonable alternative to surgery when chosen by the family. A new study has found that three out of four children with uncomplicated appendicitis have been successfully treated with antibiotics alone at one year follow-up. Compared to urgent appendectomy, non-operative management was associated with less recovery time, lower health costs and no difference in the rate of complications at one year.

Journal Reference:

  1. Peter C. Minneci, Justin B. Mahida, Daniel L. Lodwick, Jason P. Sulkowski, Kristine M. Nacion, Jennifer N. Cooper, Erica J. Ambeba, R. Lawrence Moss, Katherine J. Deans. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. JAMA Surgery, 2015; 1 DOI: 10.1001/jamasurg.2015.4534

Non-operative management of early, acute appendicitis in children: Is it safe and effective?

Jeff Armstrong,

Neil Merritt,

Sarah Jones,

Leslie Scott,

Andreana Bütter

DOI: http://dx.doi.org/10.1016/j.jpedsurg.2014.02.071

Article Info

Publication History

Published Online: February 21, 2014Accepted: February 13, 2014Received: February 10, 2014

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Abstract

Purpose

The purpose of this study was to determine if early, acute appendicitis in children can be safely and effectively managed with antibiotics alone.

Methods

A retrospective review was performed of children (<18  yrs) treated non-operatively (NOM) for early, acute appendicitis since May 2012. These were compared to patients treated with appendectomy between January 2011 and October 2011 (OM). Inclusion criteria included: (a) symptoms <48 h, (b) localized peritonitis, and (c) ultrasound findings consistent with early, acute appendicitis.

Results

Twelve patients (66% female, mean age 12.2,SD = 4.2 yrs) were treated non-operatively, while 12 (50% female, mean age 12.5,SD = 3.2 yrs) were treated operatively. Two NOM children (16.7%) required initial appendectomy. One patient developed recurrent appendicitis requiring appendectomy 7 months post-discharge. Four other NOM patients returned with symptoms but did not require admission or surgery. Two OM patients (8.3%) had hospital visits and admissions related to surgical site infections. Mean length of stay (LOS) for the first visit was 1.5 days (SD = 1.0d) (NOM) vs. 1.3 days (SD = 0.5d) (OM) (p = 0.61). Including first and subsequent admissions, mean LOS was 1.8 days (SD = 1.1d) (NOM) vs. 1.7 days (SD = 1.5d) (OM) (p = 0.97).

Conclusion

Early acute appendicitis in appropriately selected children can be successfully treated non-operatively. Randomized trials with longer follow-up are required.

Key words:

Appendicitis, Non-operative management, Antibiotics

 

Here is the press release from Nationwide Children’s Hospital:

Antibiotics Alone Can Be a Safe, Effective Treatment for Children with Appendicitis

Columbus, OH – 12/16/2015

Using antibiotics alone to treat children with uncomplicated acute appendicitis is a reasonable alternative to surgery when chosen by the family. A study led by researchers at Nationwide Children’s Hospital found that three out of four children with uncomplicated appendicitis have been successfully treated with antibiotics alone at one year follow-up. Compared to urgent appendectomy, non-operative management was associated with less recovery time, lower health costs and no difference in the rate of complications at one year.

“Families who choose to treat their child’s appendicitis with antibiotics, even those who ended up with an appendectomy because the antibiotics didn’t work, have expressed that for them it was worth it to try antibiotics to avoid surgery,” said Peter C. Minneci, MD who led the study published online Dec. 16 in JAMA Surgery with Katherine J. Deans, MD. The pair are co-directors of the Center for Surgical Outcomes Research and principal investigators in the Center for Innovation in Pediatric Practice in The Research Institute at Nationwide Children’s. “These patients avoided the risks of surgery and anesthesia, and they quickly went back to their activities.”

“Surgery has long been the ‘gold standard’ of care for treating appendicitis because by removing the appendix we eliminate the chance that the appendicitis will ever come back,” said Dr. Deans. “However, early in our careers we noticed that patients with appendicitis who were placed on antibiotics overnight until their surgery the following morning felt better the next day. So, Pete and I asked ourselves: do they really need to have surgery?”

In the first study conducted and published in the United States examining non-operative management for appendicitis, they enrolled 102 patients age 7 to 17 who were diagnosed with uncomplicated acute appendicitis at Nationwide Children’s between October 2012 and March 2013. Participants had early/mild appendicitis, meaning that they experienced abdominal pain for no more than 48 hours; had a white blood cell count below 18,000; underwent an ultrasound or CT scan to rule out rupture and to verify that their appendix was 1.1 centimeter thick or smaller; and had no evidence of an abscess or fecalith, which is hard stone-like piece of stool.

Thirty-seven families chose antibiotics alone and 65 opted for surgery. Those patients in the non-operative group were admitted to the hospital and received IV antibiotics for at least 24 hours, followed by oral antibiotics after discharge for a total of 10 days. Among those patients, 95% showed improvement within 24 hours and were discharged without undergoing surgery. Rates of appendicitis-related medical care within 30 days were similar between the groups with two patients in the non-operative group readmitted within 30 days for an appendectomy. At one year after discharge, three out of four patients in the non-operative group did not have appendicitis again and have not undergone surgery.

Appendicitis, caused by a bacterial infection in the appendix, is the most common reason for emergency abdominal surgery in children, sending more than 70,000 young people to the operating room each year. Although many of these cases are severe and require surgery, there are a good number that would be candidates for treatment with antibiotics alone, Dr. Minneci said.

“We believe that the results of our study reflect the effectiveness of offering non-operative management to patients and their families in clinical practice. The patient choice design allows the patient and family’s preference to be aligned with their choice of therapy,” said Dr. Deans. “Most parents are concerned about having surgery, in general. They’re also very concerned about anesthesia. Some parents are very concerned about appendicitis coming back. It’s really a matter of aligning your preferences, your values, what you think is most important to you, with the treatment that is best for you and your family.”

For example, explained Dr. Minneci, if the family is so afraid of a recurrence that they visit the Emergency Department every time their child has abdominal pain, then their child will likely undergo increased imaging and eventually undergo an appendectomy. In that case, letting them choose an appendectomy upfront may be better for the child.

According to the study results, patients who were transferred to Nationwide Children’s from other institutions expressed concerns about the distance and time necessary to come back if the appendicitis recurred. These families opted for surgery more often. Patients whose families spoke primary languages other than English were more likely to choose antibiotics as a course of treatment due to cultural values to avoid surgery if at all possible.

Both researchers, who are also Assistant Professors of Surgery and Pediatrics in The Ohio State University College of Medicine, say further studies are needed to see if the results they saw in this study apply in other health systems, and emphasize that the perceptions of both patient-families and surgeons can impact the study results. Their intention is to follow all the children in this study as long as possible to see if those treated with non-operative management continue to thrive.

Click here to watch a video about one of our patients who benefited from antibiotics for appendicitis. 

Nearly 200 children a day undergo emergency appendectomies in the U.S., but a new study by researchers at Nationwide Children`s Hospital in Columbus, Ohio found surgery wasn`t always necessary. Experts were able to successfully treat the majority of children with uncomplicated appendicitis with antibiotics alone. – See more at: http://www.nch.multimedianewsroom.tv/story.php?id=1108&enter=#sthash.zp5AD7M0.dpuf

Nearly 200 children a day undergo emergency appendectomies in the U.S., but a new study by researchers at Nationwide Children`s Hospital found surgery was not always necessary. Experts were able to successfully treat the majority of children with uncomplicated appendicitis with antibiotics alone.

Full citation:

Minneci PC, Mahida JB, Lodwick, DL, Sulkowski JP, Nacion KM, Cooper JN, Ambeba, EJ, Moss RL, Deans KJ. The effectiveness of patient choice in non-operative versus surgical management of uncomplicated acute appendicitis. JAMA Surgery. 2015 Dec 16 [Epub ahead of print].

http://www.nationwidechildrens.org/news-room-articles/antibiotics-alone-can-be-a-safe-effective-treatment-for-children-with-appendicitis?contentid=150302

Moi blogs about education issues so the reader could be perplexed sometimes because moi often writes about other things like nutrition, families, and personal responsibility issues. Why? The reader might ask? Children will have the most success in school if they are ready to learn. Ready to learn includes proper nutrition for a healthy body and the optimum situation for children is a healthy family. Many of society’s problems would be lessened if the goal was a healthy child in a healthy family.

Resources:

Appendicitis                                                                                                                     http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022755/

Appendicitis in Children                                                                     http://kidshealth.org/parent/infections/stomach/appendicitis.html

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