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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis

KK Varadhan, DJ Humes, KR Neal, and DN Lobo.

Review published: 2010.

Link to full article: [Journal publisher]

CRD summary

This review concluded that, although antibiotics may be used as primary treatment for selected patients with suspected uncomplicated appendicitis, appendectomy should remain the gold standard therapy for patients with acute appendicitis based on available evidence. These conclusions should be interpreted with some caution as they are based on a small number of trials with methodological limitations.

Authors' objectives

To compare antibiotic therapy alone with surgery (appendectomy) for acute appendicitis.


MEDLINE, EMBASE and the Cochrane Library were searched from 1966 to June 2009 for published studies. Search terms were reported. No language restrictions were applied.

Study selection

Randomised controlled trials (RCTs) that compared surgery (appendectomy) with antibiotic therapy alone for the treatment of adult patients (over 18 years old) with suspected acute appendicitis at initial presentation were eligible for inclusion.

The primary outcome measure was complications (as reported in the included trials). Secondary outcome measures were length of hospital stay and re-admission rates.

Patients in the included trials were admitted with a history plus clinical signs of acute appendicitis with positive laboratory tests. Patients with suspected perforated appendix or peritonitis and those with allergy to antibiotics used in the protocols were excluded. One trial also performed ultrasonography in all patients; another trial performed ultrasonography and computed tomography in selected patients.

Two reviewers independently assessed studies for inclusion.

Assessment of study quality

Trial quality was assessed using the Jadad scale, which assigned trials a score out of 5 based on randomisation, blinding and withdrawals. Trials were also assessed according to whether a consecutive series of patients was enrolled and whether there was adequate concealment of treatment allocation.

The authors did not state how many reviewers performed the quality assessment.

Data extraction

Two reviewers independently extracted data to calculate relative risks (RRs) with 95% confidence intervals (CIs).

Methods of synthesis

Summary relative risks, with 95% confidence intervals, were estimated using random-effects models. Heterogeneity was assessed using Ι² and Χ².

Results of the review

Three RCTs were included in the review (n=661 patients). All trials enrolled a consecutive series of patients and used appropriate methods of randomisation. None of the trials concealed treatment allocation or were blinded. Two trials reported an appropriate description of withdrawals. The minimum duration of follow-up was one year.

Of the 350 patients randomised to antibiotic therapy groups, 38 patients were re-admitted with recurrences (35 had appendicitis) and 112 patients crossed over to the surgery group.

There was no difference in the incidence of complications or length of hospital stay between the treatment groups. There was some evidence of heterogeneity for both analyses (complications Ι²=63%; length of hospital stay Ι²= 68%).

Authors' conclusions

Antibiotics may be used as primary treatment for selected patients with suspected uncomplicated appendicitis, but it was unlikely to supersede appendectomy. Selection bias and cross-over to surgery in the RCTs suggested that appendectomy remained the gold standard therapy for acute appendicitis.

CRD commentary

The review addressed a clear question and inclusion criteria were defined. The literature search was appropriate for published studies, but restrictions of the review to published data meant that there was a possibility of publication bias. Appropriate steps were taken to minimise bias and errors when extracting data and assessing inclusion, but it was unclear whether such steps were also taken when assessing quality.

Trial quality was assessed using appropriate criteria; the results were clearly presented. Methods used to pool data were appropriate. Results were clearly presented with the help of forest plots.

The authors' conclusions were supported by the data, but should be interpreted with some caution due to the possibility of publication bias and (as the authors acknowledged) the methodological limitations of the included trials.

Implications of the review for practice and research

Practice: The authors stated that there is evidence to support the safe use of antibiotic therapy alone in selected patients presenting with acute appendicitis where perforation or peritonitis is not suspected.

Research: The authors stated that further studies with clear inclusion and diagnostic criteria are needed to study the effects of antibiotic therapy as the first-line treatment for uncomplicated appendicitis. Reporting of outcome should be on an intention-to-treat basis rather than a per-protocol basis in order to determine the true efficacy of the treatment.


Supported in part by a research fellowship from the Nottingham Digestive Disease Centre NIHR Biomedical Research Unit.

Bibliographic details

Varadhan KK, Humes DJ, Neal KR, Lobo DN. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. World Journal of Surgery 2010; 34(2): 199-209. [PubMed: 20041249]

Indexing Status

Subject indexing assigned by NLM


Acute Disease; Anti-Bacterial Agents /therapeutic use; Appendectomy; Appendicitis /drug therapy /surgery; Humans; Randomized Controlled Trials as Topic; Treatment Outcome



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 20041249


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