UMEM Educational Pearls

Category: Gastrointestional

Title: The latest in antibiotics for appendicits

Keywords: antibiotics appendicitis (PubMed Search)

Posted: 6/12/2024 by Neeraja Murali, DO, MPH (Updated: 7/17/2024)
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By now, most of us are aware that there's evidence supporting the use of an antibiotics-only approach for acute uncomplicated appendicitis. One of the major trials evaluating this is the Appendicitis Acuta II Trial. Our paper today continued longitudinal follow up of the original cohort enrolled in this study.

Patients were randomized to receive either oral antibiotic monotherapy (moxifloxacin 400 mg/d x 7 days) or IV and oral antibiotics (IV ertapenem 1 g/d x 2 days plus oral levofloxacin 500 mg/d + metronidazole500 mg q8h x 5 d). 

Primary endpoint: resolution of acute appendicitis and hospital discharge without surgery and no reoccurence at time of follow up (3 years later).

There were 582 patients in the three year follow up cohort; Success was 63.4% (1-sided 95% CI, 58.8% to ?) in the oral antibiotics only group and 65.2% in the IV + oral antibiotics(1-sided 95% CI, 60.5% to ?). The difference in success rate was -1.8% (1-sided 95% CI, ?8.3 percentage points to ?; P?=?.14 for noninferiority).

No significant difference in secondary endpoints, including treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave. 

In this secondary analysis of the three year cohort from the APPAC II trial, there was a slightly higher appendectomy rate in patients who received oral antibiotic therapy; noninferiority of this regimen (as composed to combined) could not be demonstrated.


Selänne L, Haijanen J, Sippola S, et al. Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial. JAMA Surg. Published online April 17, 2024. doi:10.1001/jamasurg.2023.5947