Antibiotics and surgery approach in the treatment of acute uncomplicated appendicitis: Which treatment choice is novel? – Correspondence

Dear Editor, Acute appendicitis is a sudden and severe inflammation of the appendix caused by a bacterial or viral infection. It is brought on by luminal blockage from multiple etiologies, which increases the production of mucus and bacterial overgrowth, causing wall tension, necrosis, and sometimes perforation. It is characterized by peri-umbilical pain radiating to right lower quadrant, along with fever, nausea, vomiting, and loss of appetite. The appendix's variable position affects the clinical presentation, which makes diagnosis difficult, particularly in pregnant women. It is diagnosed using ultrasound, CT scan, physical examination, and blood tests. A prompt and precise diagnosis of acute appendicitis can help to decrease mortality and morbidity from appendical rupture and other complications. Acute appendicitis is one of the most common surgical diseases and is also a major cause of acute abdomen. For more than two centuries, surgery has been the basis of medical treatment for appendicitis which can be performed openly or laparoscopically. According to recent studies, laparoscopic appendectomy is the gold standard surgical treatment for appendicitis due to its reduced risk of wound infection, postoperative morbidity, shorter length of hospital stay, and better quality of life ratings when compared to open appendectomy [1]. However, new studies indicate that in selected patients with uncomplicated appendicitis, non-operative management with antibiotic therapy may be preferable to surgery, and it may be considered as a sole therapy. The benefits of antibiotic treatment over appendectomy include a lower incidence of post-intervention complications, decreased medical expenses, less sick leaves, and a lesser need for pain medications. According to the research by Sippola et al. appendectomy patients had overall societal costs that were 1.6 times greater than those patients who received antibiotics as a treatment, with significantly less sick day leaves [2]. When considering the choice of non-operative treatment for acute appendicitis, the presence of appendicolith (a calcified deposit within the appendix) is important. In 10% of individuals with appendicitis, the appendix lumen is blocked by an appendicolith. Appendicolith increases the likelihood of recurrent appendicitis and is linked to an increased risk of complicated appendicitis. The key factor contributing to antibiotic treatment failure is the presence of an appendicolith. For uncomplicated appendicitis with an appendicolith, surgery is recommended [3]. A randomized trial was conducted by “The CODA Collaborative” to compare antibiotics to appendectomy in 1522 patients using the outcome as defined by the 30-day health status. The study concluded that antibiotics were non-inferior to appendectomy. However, appendectomy was necessary for approximately 30% of patients who received antibiotic treatment over the subsequent 90 days. A total of 70% of lesser surgeries as a result of treating acute appendicitis with antibiotics can ease hospital workload and save resources, which are advantageous in the COVID-19 epidemic [4]. A meta-analysis by Podda et al. reported that antibiotic therapy used as a primary non-operative treatment for uncomplicated appendicitis to be associated with a 27.7% of treatment failure rate on follow-up at 1 year, and a lower success rate of complication-free treatment as compared to appendectomy [5]. Presently, surgery is still the mainstay of therapy. However, more research is required to determine whether antibiotic-based conservative therapy is as efficient as, or even superior to, surgery. In routine clinical practice, uncomplicated appendicitis patients should be informed that conservative therapy with antibiotics is generally a safe alternative, however, laparoscopic appendectomy is the gold standard of care. Furthermore, patients who do not wish to undergo surgery should receive conservative care, as treating them with antibiotics can relieve hospital bed load, save money and reduce the risk of surgical complications. Ethical approval NA. Source of funding NA. Author contribution All authors equally contributed. Trail registry number NA. Guarantor Govinda Khatri, Department of internal medicine, DOW University of Health Science, Karachi, Pakistan, [email protected]. Provenance and peer review Not commissioned, internally peer-reviewed. Data statement This article has not been published anywhere. The authors declare no conflict of interest. The study do not involve any human or animal subject. Declaration of competing interest NA. Aneesh Rai Deepa Kumari Priya Govinda Khatri 1Department of Internal Medicine, Dow University of Health Science, Karachi, Pakistan 2Department of Internal Medicine, People's University of Medical and Health Sciences, Nawabshah, Pakistan E-mail addresses:[email protected]