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From the Family Practice Inquiries Network

Antibiotic Treatment for Uncomplicated Acute Appendicitis in Children

Timothy Mott, MD
Carrie Gray, DO

American Family Physician. 2025;111(1):75-76.

Author disclosure: No relevant financial relationships.

CLINICAL QUESTION

Is nonoperative antibiotic therapy a practical option compared with operative treatment for uncomplicated acute appendicitis in children?

EVIDENCE-BASED ANSWER

Nonoperative treatment with antibiotics for uncomplicated acute appendicitis in children is an option but leads to higher numbers of hospital readmissions and subsequent surgeries. (Strength of Recommendation [SOR]: A, meta-analysis of randomized controlled trials [RCTs] and cohort studies.) The nonoperative approach has a treatment failure rate of approximately 20%, with most occurring in the first 2 days. (SOR: B, RCT and large cohort study.) The presence of an appendicolith visualized with ultrasonography is strongly associated with early failure of nonoperative treatment. (SOR: B, single RCT.)

EVIDENCE SUMMARY

A 2023 systematic review and meta-analysis composed of four RCTs and 13 observational studies assessed various outcomes in children with uncomplicated acute appendicitis who were treated with appendectomy or nonoperatively with antibiotics.1 Meta-analyses were performed separately on the RCTs and cohort studies for various outcomes (Table 11). Each analysis found an increased number of hospital readmissions in the nonoperative antibiotic treatment group. Also in the nonoperative antibiotic therapy group, there was an increased need for surgery beyond index assignment, and treatment occurred more often. The cohort studies analysis showed no significant differences in abscess formation, length of hospitalization, or need for an additional course of antibiotics between the two groups.

TABLE 1. Rates of Various Outcomes After Antibiotic Treatment vs Appendectomy in Children With Uncomplicated Appendicitis

OutcomeTrial/studyMagnitude of effect
Abscess formation4 cohort studies (N = 284)OR = 0.13 (95% CI, 0.01–1.29)
Length of hospitalization6 cohort studies (N = 77,146)MD = 1.4 days (95% CI, −0.61 to 3.41)
Need for additional course of antibiotics1 RCT (N = 54)
2 cohort studies (N = 68)		OR = 1.0 (95% CI, 0.06–16.85)
OR = 1.84 (95% CI, 0.33–10.13)
Hospital readmission4 RCTs (N = 193)
9 cohort studies (N = 65,688)		OR = 10.57 (95% CI, 2.3–48.7)
OR = 5.49 (95% CI, 2.6–11.6)
Need for surgery after index group assignment and treatment2 RCTs (N = 100)
6 cohort studies (N = 1,446)		OR = 38.31 (95% CI, 4.9–299.7)
OR = 54.37 (95% CI, 25.13–117.66)

Note: Text in bold type = significant outcome.

MD = mean difference; OR = odds ratio; RCT = randomized controlled trial.

Information from reference 1.

A 2021 RCT (N = 180) in Pakistan compared nonoperative treatment with appendectomy in children presenting with uncomplicated acute appendicitis.2 Children and adolescents between ages 5 and 15 years were included in the trial; 68% were male. Patients in the nonoperative group received broad-spectrum intravenous antibiotics for a minimum of 48 hours and then were transitioned to oral antibiotics for an additional 8 days. Patients in the other group underwent open appendectomy with perioperative antibiotics. The criteria used to determine failure of nonoperative treatment were need for surgery within 48 hours due to worsening symptoms, abscess formation or fluid collection as noted with ultrasonography, or recurrence of appendicitis within 6 months.

TIMOTHY MOTT, MD, and CARRIE GRAY, DO, Baldwin Health Family Medicine Residency, Foley, Alabama

Address correspondence to Timothy Mott, MD, at timothy_mott@chs.net.

Author disclosure: No relevant financial relationships.

  1. 1.Lamm R, Kumar SS, Collings AT, et al. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc. 2023;37(12):8933-8990.
  2. 2.Sajjad MN, Naumeri F, Hina S. Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: a randomized controlled trial. Pak J Med Sci. 2021;37(5):1276-1281.
  3. 3.Lipsett SC, Monuteaux MC, Shanahan KH, et al. Nonoperative management of uncomplicated appendicitis. Pediatrics. 2022;149(5):e2021054693.
  4. 4.Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):27.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email questions@fpin.org.

Copyright © Family Physicians Inquiries Network. Used with permission.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN’s Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.

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