Nonsurgical Management of Acute Uncomplicated Appendicitis in Children: the Analysis of Treatment Outcome in Relationship with Antimicrobial Regimens and Adverse Prognostic Factors
Authors: Silina Elina , Jurgele Asnate , Viksne Arturs , Abola Zane , Engelis Arnis , Petersons Aigars 
Published: August 2017

Summary

Introduction. For acute appendicitis - the most frequent condition to perform an urgent abdominal operation in pediatric surgery - surgical appendectomy still remains the gold standard regarding treatment, nevertheless nonsurgical management has become more and more recognized as a treatment method for uncomplicated acute appendicitis (UAA). However there are still many unanswered questions regarding possible factors that could predict the treatment outcome as well as appropriate antimicrobial drug regimens.

Aim of the Study. The aim was to investigate if there is a possible association between factors such as C-reactive protein (CRP) level, presence of appendicolith, the diameter of the appendix and treatment outcome; as well as to identify most successfully used antimicrobial drug combinations.

Material and methods. A retrospective analysis of hospital cases, admitted to a single reference center during the time period from 2013 to 2015. Patients with clinical signs of acute appendicitis, elevated inflammatory markers and radiological findings suggestive for acute appendicitis were included in the study. Nonsurgical treated patients were divided in two groups based on the treatment outcome - successful or unsuccessful. Analysis of the three factors (CRP level, presence of appendicolith and the diameter of the appendix) and most commonly used antimicrobial drug regimen association with treatment outcome was performed.

Results. Overall 384 children medical records with acute appendicitis were registered and non-surgical treatment was initiated in 147/384 (38 %) cases. Successful treatment outcome of nonsurgical management was identified in 114/147 (78 %) cases. Analyzing prognostic adverse factors results presents no statistically significant difference in association with CRP level >25 mg/l (p=0,479), presence of appendicolith (p=0,183) and the diameter of appendix >1 cm (p=0,183) with successful or unsuccessful treatment outcome. The two most commonly used antimicrobial drug combinations were - Ampicillin/Metronidazole for 49 patients and Ampicillin/Gentamicin for 44 patients. No relevance with treatment outcome and used antimicrobial agents was detected (p=0,597).
The overall recurrence rate after initial presentation is 15 % (17/114). In 3 cases (3 %) recurrent appendicitis developed one month after discharge and in 14 cases (12 %) up to one year after discharge.

Conclusions. Prognostic adverse factors - CRP, presence of appendicolith and diameter of appendix - were not statistically reliable in association with initial non-surgical treatment outcome. The success rate of conservative treatment with narrow spectrum antibiotics was 78 %, which is just as high as in cases treated conservatively with broad-spectrum antibiotics from previous studies. Therefore the question of which factors and antimicrobial drug combinations influence the course of treatment still remains unanswered and further studies are required.