A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial) Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. A role for conservative antibiotic treatment in early appendicitis in children. Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues? Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis. Non‐operative Management for Uncomplicated Appendicitis: An Option to Consider Risk of surgical site infection and efficacy of antibiotic prophylaxis: a cohort study of appendectomy patients in Thailand Are antibiotics necessary in nonperforated appendicitis in children? A double blind randomized controlled trial. Laparoscopy in children with complicated appendicitis. Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis Principles of Appropriate Antibiotic Use for Treatment of Acute Bronchitis in Adults Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial Effectiveness of antibiotic prophylaxis in cholecystectomy: A prospective population-based study of 1171 cholecystectomies Conservative antibiotic treatment for acute uncomplicated appendicitis is feasible Can oral metronidazole substitute parenteral drug therapy in acute appendicitis? A new policy in the management of simple or complicated appendicitis with localized peritonitis: a randomized controlled clinical trial. The outcome of antibiotic therapy for uncomplicated appendicitis with diameters ≤ 10 mm. Discharge planning for children with perforated appendicitis. Syringe Pressure Irrigation of Subdermic Tissue after Appendectomy to Decrease the Incidence of Postoperative Wound Infection Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. Uncomplicated Bacterial Communityacquired Urinary Tract Infection in Adults. The necessity of prophylactic antibiotics in uncomplicated appendicitis during childhood.
Background Although the st and ard treatment of acute appendicitis ( AA ) consists of an early appendectomy , there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA . However , the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial . Methods / design The APPAC trial is a r and omized prospect i ve controlled , open label , non-inferiority multicenter trial design ed to compare antibiotic therapy ( ertapenem ) with emergency appendectomy in the treatment of uncomplicated AA . The primary endpoint of the study is the success of the r and omized treatment . In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year ( treatment efficacy ) . Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100 % . Secondary endpoints are post-intervention complications , overall morbidity and mortality , the length of hospital stay and sick leave , treatment costs and pain scores ( VAS , visual analoque scale ) . A maximum of 610 adult patients ( aged 18–60 years ) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and r and omized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem ( 1 g per day ) for three days continued by oral levofloxacin ( 500 mg per day ) plus metronidazole ( 1.5 g per day ) for seven days . Follow-up by a telephone interview will be at 1 week , 2 months and 1 , 3 , 5 and 10 years ; the primary and secondary endpoints of the trial will be evaluated at each time point . Discussion The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75–85 % of patients with uncomplicated AA can be treated with effective antibiotic  therapy avoiding unnecessary appendectomies and the related operative morbidity , also result ing in major cost savings . Trial registration Clinical IMPORTANCE An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis . OBJECTIVE To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography ( CT ) . DESIGN , SETTING , AND PARTICIPANTS The Appendicitis Acuta ( APPAC ) multicenter , open-label , noninferiority r and omized clinical trial was conducted from November 2009 until June 2012 in Finl and . The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan . Patients were r and omly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period . INTERVENTIONS Patients r and omized to antibiotic therapy received intravenous ertapenem ( 1 g/d ) for 3 days followed by 7 days of oral levofloxacin ( 500 mg once daily ) and metronidazole ( 500 mg 3 times per day ) . Patients r and omized to the surgical treatment group were assigned to undergo st and ard open appendectomy . MAIN OUTCOMES AND MEASURES The primary end point for the surgical intervention was the successful completion of an appendectomy . The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period . RESULTS There were 273 patients in the surgical group and 257 in the antibiotic group . Of 273 patients in the surgical group , all but 1 underwent successful appendectomy , result ing in a success rate of 99.6 % ( 95 % CI , 98.0 % to 100.0 % ) . In the antibiotic group , 70 patients ( 27.3 % ; 95 % CI , 22.0 % to 33.2 % ) underwent appendectomy within 1 year of initial presentation for appendicitis . Of the 256 patients available for follow-up in the antibiotic group , 186 ( 72.7 % ; 95 % CI , 66.8 % to 78.0 % ) did not require surgery . The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0 % ( 95 % CI , -31.6 % to ∞ ) ( P = .89 ) . Given the prespecified noninferiority margin of 24 % , we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery . Of the 70 patients r and omized to antibiotic treatment who subsequently underwent appendectomy , 58 ( 82.9 % ; 95 % CI , 72.0 % to 90.8 % ) had uncomplicated appendicitis , 7 ( 10.0 % ; 95 % CI , 4.1 % to 19.5 % ) had complicated acute appendicitis , and 5 ( 7.1 % ; 95 % CI , 2.4 % to 15.9 % ) did not have appendicitis but received appendectomy for suspected recurrence . There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients r and omized to antibiotic treatment . CONCLUSIONS AND RELEVANCE Among patients with CT-proven , uncomplicated appendicitis , antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy . Most patients r and omized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period , and those who required appendectomy did not experience significant complications . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01022567 PURPOSE To evaluate whether antibiotics without surgery is sufficient treatment for children with clinical ly and ultrasonographically suspected acute appendicitis ( AA ) . METHOD Children with clinical , laboratory and radiological findings suspicious for AA were evaluated prospect ively . Patients with mild clinical signs , without peritonitis were considered for IV followed by oral antibiotics without surgery . RESULTS From 1 November 2013 through 30 June 2014 , 45 children were diagnosed with early , acute appendicitis . Ages ranged from 4 to 15 years ( mean 9.3 ) and 32 ( 75 % ) were boys . All had routine , clinical laboratory and ultrasound workup . Forty-two improved with antibiotic treatment and were discharged home within 3 - 5 days , without surgery . Three of them were operated on within 24 hours , another two underwent appendectomy for recurrent appendicitis : one at 2 weeks and the other 2 months after discharge . There was no more recurrent appendicitis in 6 - 14-month follow-up . CONCLUSION Our series of patients with AA treated with antibiotics only are a product of the observation that some children improve with antibiotics alone at a stage in which surgery is still debatable . These results ( 89 % success rate ) support the conservative approach in cases of early appendicitis , without increased morbidity in failed cases Importance Short-term results support antibiotics as an alternative to surgery for treating uncomplicated acute appendicitis , but long-term outcomes are not known . Objective To determine the late recurrence rate of appendicitis after antibiotic therapy for the treatment of uncomplicated acute appendicitis . Design , Setting , and Participants Five-year observational follow-up of patients in the Appendicitis Acuta ( APPAC ) multicenter r and omized clinical trial comparing appendectomy with antibiotic therapy , in which 530 patients aged 18 to 60 years with computed tomography – confirmed uncomplicated acute appendicitis were r and omized to undergo an appendectomy ( n = 273 ) or receive antibiotic therapy ( n = 257 ) . The initial trial was conducted from November 2009 to June 2012 in Finl and ; last follow-up was September 6 , 2017 . This current analysis focused on assessing the 5-year outcomes for the group of patients treated with antibiotics alone . Interventions Open appendectomy vs antibiotic therapy with intravenous ertapenem for 3 days followed by 7 days of oral levofloxacin and metronidazole . Main Outcomes and Measures In this analysis , prespecified secondary end points reported at 5-year follow-up included late ( after 1 year ) appendicitis recurrence after antibiotic treatment , complications , length of hospital stay , and sick leave . Results Of the 530 patients ( 201 women ; 329 men ) enrolled in the trial , 273 patients ( median age , 35 years [ IQR , 27 - 46 ] ) were r and omized to undergo appendectomy , and 257 ( median age , 33 years , [ IQR , 26 - 47 ] ) were r and omized to receive antibiotic therapy . In addition to 70 patients who initially received antibiotics but underwent appendectomy within the first year ( 27.3 % [ 95 % CI , 22.0%-33.2 % ] ; 70/256 ) , 30 additional antibiotic-treated patients ( 16.1 % [ 95 % CI , 11.2%-22.2 % ] ; 30/186 ) underwent appendectomy between 1 and 5 years . The cumulative incidence of appendicitis recurrence was 34.0 % ( 95 % CI , 28.2%-40.1 % ; 87/256 ) at 2 years , 35.2 % ( 95 % CI , 29.3%-41.4 % ; 90/256 ) at 3 years , 37.1 % ( 95 % CI , 31.2%-43.3 % ; 95/256 ) at 4 years , and 39.1 % ( 95 % CI , 33.1%-45.3 % ; 100/256 ) at 5 years . Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis , 76 had uncomplicated appendicitis , 2 had complicated appendicitis , and 7 did not have appendicitis . At 5 years , the overall complication rate ( surgical site infections , incisional hernias , abdominal pain , and obstructive symptoms ) was 24.4 % ( 95 % CI , 19.2%-30.3 % ) ( n = 60/246 ) in the appendectomy group and 6.5 % ( 95 % CI , 3.8%-10.4 % ) ( n = 16/246 ) in antibiotic group ( P < .001 ) , which calculates to 17.9 percentage points ( 95 % CI , 11.7 - 24.1 ) higher after surgery . There was no difference between groups for length of hospital stay , but there was a significant difference in sick leave ( 11 days more for the appendectomy group ) . Conclusions and Relevance Among patients who were initially treated with antibiotics for uncomplicated acute appendicitis , the likelihood of late recurrence within 5 years was 39.1 % . This long-term follow-up supports the feasibility of antibiotic treatment alone as an alternative to surgery for uncomplicated acute appendicitis . Trial Registration Clinical Trials.gov Identifier : Introduction : The management approach for acute appendicitis has been challenged in recent years , with numerous r and omized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment , with lower complication rates . Methods : A national survey of all consultant general surgeons evaluating their practice s was performed . Reasons for changed practice s , choice of antibiotics and follow-up investigations were evaluated . In addition , the role of interval appendicectomy and conservative management in the pediatric population was also assessed . Results : The response rate for this survey was 74.7 % ( n = 74/99 ) . Over one-fifth ( n = 17 , 22.9 % ) routinely treat acute appendicitis conservatively , while another 14.8 % ( n = 11 ) consider this approach in selected cases . Main reasons for modified practice s included the presence of inflammatory phlegmon ( 75 % ) , delayed presentation ( 64 % ) , and recent evidence -based medicine developments ( 46 % ) . Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management ( 53 % ) . Alternatively , combinations of antibiotics were also utilized . One-third felt interval appendicectomy was warranted , while one-fifth supported conservative management in the paediatric setting . The overwhelming majority ( > 95 % ) advocate follow-up colonoscopy ± computed tomography in any patient aged > 40 years managed conservatively . Conclusion : Considerable variation in management of uncomplicated appendicitis  remains in Irel and despite growing evidence suggesting that the non-operative approach is safe . Reasons for adopting a conservative management practice have been identified and reflect the exp and ing literature on this subject An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis . The objective of this study was to compare the costs of antibiotics alone  versus  appendicectomy  in treating uncomplicated acute appendicitis within the r and omized controlled APPAC ( APPendicitis ACuta ) trial IMPORTANCE Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe , but overall effectiveness is determined by combining medical outcomes with the patient 's and family 's perspective , goals , and expectations . OBJECTIVE To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1 , 2012 , through March 6 , 2013 . Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy . INTERVENTIONS Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and , on demonstrating improvement of symptoms , completion of 10 days of treatment with oral antibiotics . MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year success rate of nonoperative management . Successful nonoperative management was defined as not undergoing an appendectomy . Secondary outcomes included comparisons of the rates of complicated appendicitis , disability days , and health care costs between nonoperative management and surgery . RESULTS A total of 102 patients were enrolled ; 65 patients /families chose appendectomy ( median age , 12 years ; interquartile range [ IQR ] , 9 - 13 years ; 45 male [ 69.2 % ] ) and 37 patients /families chose nonoperative management ( median age , 11 years ; IQR , 10 - 14 years ; 24 male [ 64.9 % ] ) . Baseline characteristics were similar between the groups . The success rate of nonoperative management was 89.2 % ( 95 % CI , 74.6%-97.0 % ) at 30 days ( 33 of 37 children ) and 75.7 % ( 95 % CI , 58.9%-88.2 % ) at 1 year ( 28 of 37 children ) . The incidence of complicated appendicitis was 2.7 % in the nonoperative group ( 1 of 37 children ) and 12.3 % in the surgery group ( 8 of 65 children ) ( P = .15 ) . After 1 year , children managed nonoperatively compared with the surgery group had fewer disability days ( median [ IQR ] , 8 [ 5 - 18 ] vs 21 [ 15 - 25 ] days , respectively ; P < .001 ) and lower appendicitis-related health care costs ( median [ IQR ] , $ 4219 [ $ 2514-$7795 ] vs $ 5029 [ $ 4596-$5482 ] , respectively ; P = .01 ) . CONCLUSIONS AND RELEVANCE When chosen by the family , nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis , incurring less morbidity and lower costs than surgery . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01718275 Abstract Aim The main goal of our study was to assess a 7 days long course of antibiotics for acute uncomplicated appendicitis . Material s and Methods From March 2014 to November 2015 , all patients diagnosed with acute appendicitis have been considered to be treated by only antibiotics .  Inclusion criteria included clinical ( tenderness ) , biological ( C‐reactive protein [ CRP ] < 50 ) , and radiological features ( diameter > 6 mm ) . All patients were treated with intravenous amoxicillin and clavulanic acid ( 100 mg/kg/day ) for 2 days ( six doses ) . At the end of the treatment , clinical and para clinical examinations included blood sample s at day 7 and ultrasound ( US ) scan at 3 months . Results A total of 166 patients were treated and followed up prospect ively during the study period . Mean age at diagnosis was 10.8 ± 0.6 years . All children , but four were discharged with a clinical improvement after 48 hours and six intravenous antibiotics injection according to our protocol . Four children required surgery during the initial hospitalization period . Initial ultrasound scan showed a mean diameter of 7.85 ± 1.6 mm , with inflamed fat in 124 patients ( 74.7 % ) . At Day 7 , the diameter was 5.2 ± 1.6 mm ( p < 0.0001 ) . During a median follow‐up of 18.8 months ( 3.5‐18 ) , 22 patients ( 13.25 % ) had to be managed for a novel episode of acute appendicitis after a median period of 138 days ( 13‐270 ) . None had to be managed for a complicated appendicitis . Conclusion Non‐operative treatment ( NOT ) is a safe alternative for the management of uncomplicated acute appendicitis in children . Further study should be conducted to determine relapse risk factors Background No data currently exist about use of antibiotics to prevent surgical site infections ( SSI )  among patients undergoing appendectomy in Thail and . We therefore examined risk factors , use , and efficacy of prophylactic antibiotics for surgical site infection SSI among patients with uncomplicated open appendectomy . Methods From July 1 , 2003 to June 30 , 2004 we conducted a prospect i ve cohort study in eight hospitals in Thail and . We used the National Nosocomial Infection Surveillance ( NNIS ) system criteria to identify SSI associated with appendectomy . We used logistic regression analysis to obtain relative risk estimates for predictors of SSI . Results Among 2139 appendectomy patients , we identified 26 SSIs , yielding a SSI rate of 1.2 infections/100 operations . Ninety-two percent of all patients ( 95 % CI , 91.0–93.3 ) received antibiotic prophylaxis . Metronidazole and gentamicin were the two most common antibiotic agents , with a combined single dose administered in 39 % of cases . In 54 % of cases , antibiotic prophylaxis was administered for one day . We found that a prolonged duration of operation was significantly associated with an increased SSI risk . Antibiotic prophylaxis was significantly associated with a decreased risk of SSI regardless of whether the antibiotic was administered preoperatively or intraoperatively . Compared with no antibiotic prophylaxis , SSI relative risks for combined single-dose of metronidazole and gentamicin , one-day prophylaxis , and multiple-day antibiotic prophylaxis were 0.28 ( 0.09–0.90 ) , 0.30 ( 0.11–0.88 ) and 0.32 ( 0.10–0.98 ) , respectively . ConclusionS ingle-dose combination of metronidazole and gentamicin seems sufficient to reduce SSIs in uncomplicated appendicitis patients despite whether the antibiotic was administered preoperatively or intraoperatively BACKGROUND The use of antibiotics in uncomplicated appendicitis in children , remains the area of controversy . The aim of the study was to assess the necessity of antibiotic administration in nonperforated appendicitis in children . MATERIAL AND METHODS The design of the study was a double blind r and omized controlled trial , with a follow-up of 4 to 20 months . SETTING Surgical Department in a University Pediatric Hospital . PATIENTS One hundred and eighty seven out of 249 children subjected to emergency appendectomies met the inclusion criteria , with 35 eligible but not included in the study . The remaining 152 patients were r and omized ; 41 had complicated appendicitis , 3 other diagnosis , 108 were analyzed within 3 study groups : 1 ( n = 31 ) no antibiotic , 2 ( n = 41 ) one dose , 3 ( n = 36 ) 5-day course . Open appendectomy was a surgical procedure and Ceftriaxone 1.0 g i.v . was administered . Investigated parameters were : body temperature , WBC , bowel sounds , wound healing , recovery and morbidity . RESULTS Valid outcome data were available for 90 of 108 r and omized patients . Protocol s of 18 children due to fever > 39 degrees C , upper airway infection or allergy were disclosed . In the remaining 90 children , there were no differences in WBC and oral feeding between groups 1 ( n = 24 ) , 2 ( n = 35 ) and 3 ( n = 31 ) . Group 1 and 2 had a higher mean temperature on day 1 post-op , without any clinical significance . A higher mean temperature was noted on day 5 post-op in group 1 , due to wound infection in one patient . There were no intraabdominal abscesses . The only other complications were 2 adhesion small bowel obstructions ( in groups 1 and 2 each ) . CONCLUSION Routine use of antibiotics in nonperforated appendicitis in children is not necessary BACKGROUND / PURPOSE Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children . The role of laparoscopy in complicated acute appendicitis is more controversial . The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis . METHODS A total of 102 children with suspected acute appendicitis were selected r and omly to undergo either a laparoscopic or an open appendectomy . The outcomes of 25 children with complicated appendicitis , 13 in the laparoscopic group and 12 in the open appendectomy group , were analyzed . Children , their parents , and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation . All 25 children completed a 30-day follow-up . RESULTS There were no differences in terms of patients ' age , sex , weight , height , and appendiceal histology between the 2 groups . All laparoscopic procedures were completed without conversion . The mean ( + /-SD ) operating time was 63 ( + /-31 ) minutes in the laparoscopic group and 37 ( + /-18 ) minutes in the open appendectomy group ( mean difference 26 minutes , 95 % CI 5 to 47 minutes , P = .02 ) . There were 2 major complications in the laparoscopic group in children with appendiceal masses . One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation . Another child had a pelvic abscess that resolved with antibiotic treatment . Superficial wound infections were encountered in 2 patients in the open appendectomy group . CONCLUSIONS Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis . Good surgical judgement is necessary in patients with an established appendiceal abscess Uncomplicated appendicitis may resolve spontaneously or require treatment with antibiotics or appendicectomy . The aim of this r and omized trial was to compare the outcome of a non‐antibiotic management strategy with that of antibiotic therapy in uncomplicated appendicitis In this guideline , evidence is presented and specific recommendations are made about how clinicians can differentiate between bacterial and viral causes of acute bronchitis and about when the use of antibiotics in acute bronchitis is beneficial . The numbers in square brackets are cross-references to the numbered sections in the accompanying background paper , Principles of Appropriate Antibiotic Use for Treatment of Acute Bronchitis in Adults : Background , which is part 2 of this guideline ( see pages 521 - 529 ) . Acute Bronchitis Acute bronchitis is a clinical diagnosis , usually referring to an acute respiratory tract infection in which cough , with or without phlegm , is a predominant feature . The American College of Chest Physicians defines acute cough illness , in contrast to chronic or persistent cough , as lasting less than 3 weeks . As one might expect , there is frequent overlap in how clinicians assign each diagnosis . For example , some clinicians diagnose acute bronchitis only when productive cough is present ; others insist on the presence of purulent sputum [ 1.1 ] . Acute upper respiratory tract infection accounted for approximately 70 % of primary diagnoses in adults presenting for an ambulatory office visit with a chief symptom of cough . Asthma and pneumonia were the next most common diagnoses , assigned to 6 % and 5 % of patients , respectively . Previously undiagnosed asthma is a consideration in patients presenting with an acute cough illness . However , in the setting of acute cough ( < 2 to 3 weeks ' duration ) , the diagnosis of asthma is difficult to establish because of transient bronchial hyperresponsiveness ( and abnormal results on spirometry ) , which many patients with uncomplicated acute bronchitis will have . Since pneumonia is the third most common cause of acute cough illness and potentially the most serious , the primary diagnostic objective should be to exclude the presence of pneumonia [ 1.11.3 ] . Diagnosis An evidence - and quality -based review of four prospect i ve studies evaluating the accuracy of history and physical examination in diagnosing radiographic pneumonia concluded that absence of abnormalities in vital signs ( heart rate 100 beats/min , respiratory rate 24 breaths/min , or oral temperature 38 C ) and chest examination ( focal consolidationfor example , rales , egophony , and fremitus ) sufficiently reduces the likelihood of pneumonia to the point where further diagnostic testing is usually not necessary . Cough lasting longer than 3 weeks exceeds the case definition for acute bronchitis ; such patients should be considered to have persistent cough or chronic cough illness . Irwin and colleagues have developed a well-defined approach to the adult with persistent cough that begins with chest radiography ( 1 ) [ 1.3 , 1.4 ] . As in community-acquired pneumonia , microbiological studies of uncomplicated acute bronchitis identify a pathogen in the minority of cases , ranging from 16 % to 40 % . This variability is most likely due to the epidemic nature of agents that produce uncomplicated acute bronchitis and to limitations in viral and bacterial identification techniques . In epidemiologic studies , respiratory viruses , particularly influenza , appear to cause the majority of cases of uncomplicated acute bronchitis when an agent is sought by culture , antibody serology , or polymerase chain reaction . Specific viruses most frequently associated with acute bronchitis include those that produce primarily lower respiratory tract disease ( influenza B , influenza A , parainfluenza 3 , and respiratory syncytial virus ) , as well as viruses that more commonly produce upper respiratory tract symptoms ( corona virus , adenovirus , and rhinoviruses ) [ 2.1 ] . Unless bacterial superinfection is present ( defined as pneumonia with an infiltrate on chest radiography ) , antibiotic treatment does not affect the clinical course of viral respiratory infection . To date , only Bordetella pertussis , Mycoplasma pneumoniae , and Chlamydia pneumoniae ( TWAR ) have been established as nonviral causes of uncomplicated acute bronchitis in adults . As a group , these agents are associated with 5 % to 10 % of total cases of uncomplicated acute bronchitis in adults . No evidence indicates that Streptococcus pneumoniae , Haemophilus influenzae , or Moraxella catarrhalis produce acute bronchitis in adults without underlying lung disease . Since Gram stain and culture of sputum do not reliably detect M. pneumoniae , C. pneumoniae , or B. pertussis , these tests are not recommended in the evaluation of patients with uncomplicated acute bronchitis [ 2.2 ] . Treatment On the basis of the microbiology of acute bronchitis , it should not be surprising that r and omized , placebo-controlled trials have failed to support a role for antibiotic treatment . By the mid-1990s , published review s of r and omized , placebo-controlled trials had concluded that routine antibiotic treatment of acute bronchitis does not have a consistent impact on duration or severity of illness or on potential complications , such as development of pneumonia . Consistent with these conclusions , the U.S. Food and Drug Administration removed uncomplicated acute bronchitis ( and secondary bacterial infections of acute bronchitis ) as an indication for r and omized , controlled trials of antimicrobial therapy in 1998 . Since then , three meta-analyses have been published ; all reported no impact of antibiotic treatment on illness duration , activity limitation , or work loss , and all concluded that routine antibiotic treatment of adults with acute bronchitis is not justified [ 3.0 , 3.1 ] . The one uncommon circumstance for which evidence supports antibiotic treatment of uncomplicated acute bronchitis is suspicion of pertussis . Selected studies have identified pertussis in up to 10 % to 20 % of patients with cough lasting longer than 2 to 3 weeks . Unfortunately , no clinical features allow clinicians to distinguish adults with persistent cough due to pertussis , primarily because pertussis in adults with previous immunity does not lead to the classic features of whooping cough seen in patients ( usually children ) with primary infection . Therefore , clinicians should limit suspicion and treatment of adult pertussis to patients with a high probability of exposure to pertussis : for example , during documented outbreaks . Antimicrobial therapy of suspected pertussis in adults is recommended primarily to decrease shedding of the pathogen and spread of disease , since antibiotic treatment does not appear to improve resolution of symptoms if it is initiated 7 to 10 days after the onset of illness . Because of the public health implication s , diagnostic testing in consultation with local public health officials is appropriate for surveillance purpose s [ 3.2 ] . Clinicians caring for patients with uncomplicated acute bronchitis should be encouraged to discuss the lack of benefit of antibiotic treatment for uncomplicated acute bronchitis and stop prescribing for this condition as a st and ard of practice . Patients frequently expect to receive antibiotics for uncomplicated acute bronchitis , but this expectation appears to derive from previous episodes of uncomplicated acute bronchitis that were treated with antibiotics . Mounting evidence indicates that patient satisfaction with the office encounter for uncomplicated acute bronchitis does not depend on receipt of an antibiotic but instead is related to the patient-centered quality of the encounter ( for example , believing that the provider spent enough time with them and explained the illness and treatment plan ) . Discussion should provide the patient with realistic expectations for the duration of cough ( typically 10 to 14 days ) , the side effects of antibiotics and subsequent risk for carriage of resistant bacteria , and the ineffectiveness of antibiotics [ 4.0 ] . Since the most common pathogen isolated in patients with uncomplicated acute bronchitis is influenza , discussion of the recent advances in influenza therapy is warranted . The new class of anti-influenza agents , the neuroaminidase inhibitors , are active against both influenza A and B , whereas the previously available drugs amantadine and rimantadine are active only against influenza A. For any of these antiviral agents to be effective , influenza must be diagnosed and treatment initiated within 48 hours of symptom onset . During documented influenza outbreaks , the positive predictive value of clinical diagnosis based on clinician judgment appears to be as accurate as available rapid diagnostic tests for influenza , which have reported sensitivities of 63 % to 81 % . Clinical diagnosis of influenza becomes much less accurate outside of outbreak periods . All of these drugs have a similar impact on the course of influenza illness : about 1 less day of illness and about one-half day sooner return to normal activities . Patients and physicians ( and payers ) will need to weigh the high cost of the newer drugs and the possibility of the emergence of viral resistance against the degree to which the duration of symptoms and illness is shortened [ 3.3 ] . Summary Evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out pneumonia . In the healthy , nonelderly adult , pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds , and chest radiography is usually not indicated . In patients with cough lasting 3 weeks or longer , chest radiography is warranted in the absence of other known causes . Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended , regardless of duration of cough . In the unusual circumstance in which pertussis is suspected , a diagnostic test should be performed and antimicrobial therapy initiated . Patient satisfaction with care for acute bronchitis is most dependent on physicianpatient communication rather than on whether an antibiotic is prescribed . Recommendations Recommendation 1 . The evaluation of adults with an acute cough illness or a BACKGROUND Research ers have suggested that antibiotics could cure acute appendicitis . We assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendicectomy for treatment of patients with uncomplicated acute appendicitis . METHODS In this open-label , non-inferiority , r and omised trial , adult patients ( aged 18 - 68 years ) with uncomplicated acute appendicitis , as assessed by CT scan , were enrolled at six university hospitals in France . A computer-generated r and omisation sequence was used to allocate patients r and omly in a 1:1 ratio to receive amoxicillin plus clavulanic acid ( 3 g per day ) for 8 - 15 days or emergency appendicectomy . The primary endpoint was occurrence of postintervention peritonitis within 30 days of treatment initiation . Non-inferiority was shown if the upper limit of the two-sided 95 % CI for the difference in rates was lower than 10 percentage points . Both intention-to-treat and per- protocol analyses were done . This trial is registered with Clinical Trials.gov , number NCT00135603 . FINDINGS Of 243 patients r and omised , 123 were allocated to the antibiotic group and 120 to the appendicectomy group . Four were excluded from analysis because of early dropout before receiving the intervention , leaving 239 ( antibiotic group , 120 ; appendicectomy group , 119 ) patients for intention-to-treat analysis . 30-day postintervention peritonitis was significantly more frequent in the antibiotic group ( 8 % , n=9 ) than in the appendicectomy group ( 2 % , n=2 ; treatment difference 5·8 ; 95 % CI 0·3 - 12·1 ) . In the appendicectomy group , despite CT-scan assessment , 21 ( 18 % ) of 119 patients were unexpectedly identified at surgery to have complicated appendicitis with peritonitis . In the antibiotic group , 14 ( 12 % [ 7·1 - 18·6 ] ) of 120 underwent an appendicectomy during the first 30 days and 30 ( 29 % [ 21·4 - 38·9 ] ) of 102 underwent appendicectomy between 1 month and 1 year , 26 of whom had acute appendicitis ( recurrence rate 26 % ; 18·0 - 34·7 ) . INTERPRETATION Amoxicillin plus clavulanic acid was not non-inferior to emergency appendicectomy for treatment of acute appendicitis . Identification of predictive markers on CT scans might enable improved targeting of antibiotic treatment .  FUNDING French Ministry of Health , Programme Hospitalier de Recherche Clinique 2002 Abstract Background . The aim of this study was to assess the benefit from antibiotic prophylaxis ( AP ) during cholecystectomy in a population -based cohort study . Methods . All cholecystectomies performed in Uppsala County , 2003–2005 , were registered prospect ively according to a st and ardized protocol . High-risk procedures ( HP ) were defined as operations for acute cholecystitis and procedures including exploration of the common bile duct . Infections requiring surgical or percutaneous drainage and non-surgical infections that prolonged hospital stay were defined as major infectious complications ( IC ) . Results . Altogether 1171 patients underwent cholecystectomy .  AP was given to 130 of 867 ( 15 % ) of the patients undergoing low-risk procedures ( LP ) and 205 of 304 ( 67 % ) of those undergoing H-R P.  Major IC were seen in 6 of 205 ( 3 % ) of the patients undergoing H-R P with AP and 1 of 99 of the patients undergoing H-R P without AP . No major IC was seen after L-R P. Minor IC were seen after 5 of 205 ( 2 % ) HP with AP , 1 of 99 ( 1 % ) HP without AP , 0 of 130 ( 0 % ) LP with AP , and 2 of 737 ( 0.3 % ) LP without AP . In univariate logistic analysis , the overall risk for IC was found to be higher with AP ( p < 0.05 ) , but the increase did not remain significant if adjusting for age , gender , ASA class , H-R P/L-R P and surgical approach or limiting the analysis to major IC . Conclusion . There is no benefit from AP in uncomplicated procedures . The effectiveness of antibiotic prophylaxis in complicated cholecystectomy must be evaluated in r and omized controlled trials Purpose Appendectomy versus conservative antibiotic treatment ( CAT ) for children with acute uncomplicated appendicitis ( AUA ) remains unresolved , with concerns regarding the practicality of CAT . We analyzed our center ’s experience with CAT for AUA , using a protocol with strict inclusion , exclusion and treatment criteria . Methods Non-r and omized , prospect i ve cohort study included all children admitted betwee 2014 and 2016 , with clinical and laboratory tests suspicious for AUA . Data collected included clinical signs and symptoms ; laboratory , ultrasound and pathology results . Follow-up was conducted through clinic visits , telephone conversations and national registry analysis . Results Included in CAT : 362 children , 19 underwent appendectomy within 1–2 days . Overall , 75 were readmitted for recurrent acute appendicitis during 22 months ( 6–43 ) follow-up . Thirty were treated successfully with antibiotics a second time . The remaining 45 had appendectomy . Overall , 86.8 % underwent CAT with no surgery . Histology of all recurrent AUA revealed no perforations . Conclusion We confirm the feasibility of conservative management of AUA in children . A rigorous diagnostic plan with strict inclusion and exclusion criteria will lead to high success rate of CAT with a strong safety profile . CAT does not compete with surgery or render appendectomy unnecessary . It is a safe alternative to surgery in selected cases To demonstrate the efficacy of oral metronidazole ( OM ) in simple or complicated appendicitis with localized peritonitis , a r and omized prospect i ve study was carried out in 1083 patients , ranging in age from 4 to 50 years ( mean age , 21.38 ) . The patients were r and omly divided into two groups . The study group ( SG ) ( 524 patients ) received OM ( 500 mg for adults , 7 - 10 mg/kg if less than 15 years ) 2 - 3 hours before operation . The drug was continued 4 to 5 hours after operation , every 8 hours , for three doses if the appendix was mild to severely inflamed . In the case of complicated appendicitis ( 114 patients ) , the same dose was given for 3 to 6 days , depending on the absence or presence of pus . Ceftizoxime was administered to the control group ( CG ) ( 559 patients ) 2 to 3 hours before operation and then postoperatively every 6 hours for three doses if the appendix was mild to severely inflamed . The complicated cases in the CG ( 120 patients ) received a combination of penicillin , chloramphenicol , and gentamicin for 3 to 6 days , depending on the absence or presence of pus . The serum concentration of metronidazole  measured in 43 patients was at bactericidal level in 40 ( mean + /- SD st and ard deviation , 10.65 + /- 4.89 microg/mL ) . The rate of wound infection was not significantly different in the SG and the CG with the same degree of pathology ( 3.17 % vs 2.96 % if uncomplicated ; 15.78 % vs 14.16 % if complicated , respectively ) . Pelvic collection occurred in four adults and one child in the CG with perforated appendicitis ( 4.16 % ) . The same complication developed in two adults and two children in the SG with perforated appendicitis ( 3.5 % ) . All six adults and one of the children in the SG had to be re-explored , whereas the remaining two children responded to conservative management  ( OM and gentamicin ) . In uncomplicated cases , hospital stay and hospital charge were both almost the same in both groups . However , length of hospitalization was nearly 1 day shorter and hospital cost per day was about 30 per cent less in complicated cases in the SG as compared with the CG . Conclusively , OM may not only substitute parenteral antibiotics in acute appendicitis as a prophylactic agent , but it may also be used as a cost-effective drug and is more convenient to the patient PURPOSE Although many patients receive antibiotic therapy for uncomplicated appendicitis , the relatively high treatment failure and recurrence rates are problematic . We assumed that patients with appendicitis and appendiceal diameters ≤ 10 mm , have better outcomes . The purpose of this prospect i ve non-r and omized study was to assess the outcomes of antibiotic therapy in patients with uncomplicated appendicitis and appendiceal diameters ≤ 10 mm . METHODS Over 2 years , we enrolled 119 patients who initially received antibiotic therapy .  The failure of antibiotic therapy was defined as the need for appendectomy and true appendicitis . Peritonitis was defined as either complicated appendicitis or intra-abdominal abscess postoperatively . We evaluated the rates of treatment failure , peritonitis , and recurrence . RESULTS Nine patients ( 7.6 % ) failed to respond to initial antibiotic therapy , and 6 had true appendicitis after subsequent surgery . Two patients had complicated appendicitis ( peritonitis ) , but no patient displayed intra-abdominal abscess postoperatively . During a median follow-up period months of 14 months , 14 patients ( 12.7 % ) experienced recurrence . CONCLUSIONS Antibiotic therapy without surgery may be a safe treatment for uncomplicated appendicitis in select patients with appendiceal diameters ≤ 10 mm Optimal management of children with perforated appendicitis remains a controversial clinical problem . Until very recently , the criteria for hospital discharge on our surgical service included the absence of fever and leukocytosis for a period of 48 hours following completion of antimicrobial therapy , uncomplicated wound healing , a normal rectal examination , and unimpaired gastrointestinal function . With the introduction of cost-containment programs , the necessity for the period of inpatient observation following cessation of antibiotics was question ed . The records of 87 consecutive children with perforated appendicitis were analyzed prospect ively in order to determine if our discharge policies were medically sound and cost-effective . Seventy-five patients ( 86 % ) recovered uneventfully while 12 children required prolonged hospitalization for management of various postoperative complications . The 12 patients who developed complications were all identifiable early in the postoperative period because of persistent fever , leukocytosis , and elevated b and counts . Of the 75 children who recovered uneventfully , all met st and ard discharge criteria on the final day of antibiotic therapy with the exception of completing the m and atory 48-hour period of inpatient observation . These children were maintained in the hospital a total of 142 additional days following discontinuation of antibiotics . The average cost per patient day for children with perforated appendicitis during the study period was $ 506.32 , which represented unnecessary hospital charges of $ 71,897.44 . It was concluded that inpatient observation following cessation of antibiotic therapy in children who experience an uneventful recovery from perforated appendicitis is neither necessary nor cost-effective . ( ABSTRACT TRUNCATED AT 250 WORDS To evaluate syringe pressure irrigation of the surgical wound to decrease its infection after appendectomy , we design ed a r and omized control trial at the Emergency Department of Mexico City General Hospital , including 350 patients with acute abdomen suggestive of appendicitis , without any other infection clinical ly evident . The trial was r and omized into 2 groups . Group I patients received prophylactic systemic antibiotics before surgery . Group II patients received the same prophylactic systemic antibiotics plus syringe pressure irrigation of the surgical wound with 300 ml of saline solution using a 20-ml syringe with 19-gauge intravenous ( IV ) catheter to measure the incidence of postoperative wound infection . In our results , 283 patients had appendicitis . Of these , 188 were uncomplicated ( 66.4 % ) and 95 ( 33.6 % ) were complicated . Of the complicated cases , 40 were assigned to group I , and of these , 29 ( 72.5 % ) developed wound infection . In group II there were 55 patients and only 9 ( 16.3 % ) developed wound infection after syringe pressure irrigation [ p= 0.000001 ; 95 % confidence interval ( CI ) = 0.02–0.22 ] . We conclude that syringe pressure irrigation of the surgical wound after appendectomy contributes significantly to decrease the incidence of postoperative wound infection in complicated cases . It is a cheap , safe , and accessible method in any surgical room PURPOSE Urgent appendectomy has long been the st and ard of care for acute appendicitis . Six r and omized trials have demonstrated that antibiotics can safely treat appendicitis , but approximately 1 in 4 of these patients eventually requires appendectomy . Overall treatment success may be limited by complex disease including perforation . Patients ׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging . However , the effectiveness of computed tomography ( CT ) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined . The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis . METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015 .  CT scans were re- review ed by abdominal imaging fellowship-trained radiologists using st and ardized criteria , and the radiologists were blinded to pathology and surgical findings . Radiologists specifically noted presence or absence of periappendiceal gas , abscess , appendicolith , fat str and ing , and bowel wall thickening . The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports . Pathology reports were considered the st and ard for diagnostic accuracy . RESULTS Eighty-nine patients ( 65 % male , average age of 34 years ) presenting with right lower quadrant pain  underwent CT imaging and prompt appendectomy . Final pathology reported perforation in 48 % ( n = 43 ) of cases . Radiologic diagnosis of perforation was reported in 9 % ( n = 8) , correctly identifying perforation in 37.5 % ( n = 3 ) , and incorrectly reporting perforation in 62.5 % of nonperforated cases per pathology . Radiology missed 93 % ( n = 40 ) of perforations postoperatively diagnosed by pathology . There was no secondary finding ( fat str and ing , diameter > 13 mm , abscess , cecal wall thickening , periappendiceal gas , simple fluid collection , appendicolith , and phlegmon ) with a clinical ly reliable sensitivity or specificity to predict perforated appendicitis . Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28 % of cases . CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited , and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options BACKGROUND Uncomplicated bacterial community-acquired urinary tract infection is among the more common infections in outpatient practice . The resistance level of pathogens has risen markedly . This S3 guideline contains recommendations based on current evidence for the rational use of anti - microbial agents and for the prevention of inappropriate use of certain classes of antibiotics and thus of the result ing drug resistance . The prevention of recurrent urinary tract infection is considered in this guideline for the first time . METHODS The guideline was up date d under the aegis of the German Urological Society ( Deutsche Gesellschaft für Urologie ) . A systematic literature search ( period : 2008 - 2015 ) concerning the diagnosis , treatment , and prevention of uncomplicated urinary tract infections was carried out in the Cochrane Library , MEDLINE , and Embase data bases . R and omized , controlled trials and systemic review s were included . Relevant guidelines were identified in a guideline synopsis . RESULTS Symptom-oriented diagnostic evaluation is highly valued . For the treatment of cystitis , fosfomycin-trometamol , nitrofurantoin , nitroxolin , pivmecillinam and trimethoprim are all equally recommended . Fluorquinolones and cephalosporins are not recommended . Uncomplicated pyelonephritis with a mild to moderate clinical course ought to be treated with oral cefpodoxime , ceftibuten , ciprofloxacin , or levofloxacin . For acute , uncomplicated cystitis , with mild to moderate symptoms , symptomatic treatment alone may be considered instead of antibiotics after discussion of the options with the patient . Mainly non-antibiotic measures are recommended for prophylaxis against recurrent urinary tract infection . CONCLUSION Physicians who treat uncomplicated urinary tract infections should familiarize themselves with the newly revised guideline 's recommendations on the selection and dosage of antibiotic treatment so that they can responsibly evaluate and plan antibiotic treatment for their affected patients A prospect i ve , r and omized , clinical study was done to evaluate the place of  prophylactic antibiotics  in uncomplicated childhood appendicitis . One hundred patients with uncomplicated appendicitis were r and omly assigned to one of four groups , each consisting of 25 cases . Group 1 patients did not receive prophylactic antibiotic . Group 2 , group 3 , and group 4 patients received ornidazole , penicillin plus tobramycin , and piperacillin , respectively . The use of prophylactic antibiotics did not yield better results than the use of placebos . The rarity of infectious complications after uncomplicated appendicectomy may be unique for children . Although the need for antibiotic prophylaxis is well documented in adults , the rarity of infectious complications makes it highly question able in the treatment of uncomplicated appendicitis in children
With significantly higher efficacy and low complication rates , appendectomy remains the most effective treatment for patients with uncomplicated AA .
BACKGROUND Acute appendicitis is the most common surgical diagnosis in young patients , with lifetime prevalence of about 7 % .
Debate remains on whether uncomplicated AA should be operated or not .
Aim of this meta- analysis of r and omized controlled trials was to assess current evidence on antibiotic treatment for uncomplicated AA compared to st and ard surgical treatment .