Antibiotic therapy is a safe, efficient, feasible, and cost-effective alternative to appendectomy for patients with computed tomography (CT)–confirmed uncomplicated acute appendicitis at short-term and long-term follow-up.1-5 The World Society of Emergency Surgery 2020 guideline recommended discussing antibiotics as a safe alternative to surgery for uncomplicated acute appendicitis without appendicolith (high quality of evidence; strong recommendation).6 During the coronavirus disease 2019 (COVID-19) pandemic, this was also acknowledged by the American College of Surgeons (COVID-19 Guideline for Triage of Emergency General Surgery Patients).7

In the first APPAC trial, at the 5-year follow-up, 61% of 256 patients who initially presented with uncomplicated acute appendicitis were successfully treated with antibiotics, and those who ultimately developed recurrent appendicitis had no adverse outcomes related to the delay in appendectomy.2 Quality of life was also similar after these 2 treatment alternatives.8,9 In previous trials, the length of hospital stay for both antibiotics and appendectomy has been similar,10 but for antibiotics alone, hospitalization was required to administer broad-spectrum intravenous antibiotics to ensure patient safety.1,9,11 Successful outpatient treatment has since been reported.12 Despite prolonged hospitalizations, antibiotic therapy is associated with significantly lower treatment costs compared with appendectomy.3,4 A shorter hospital stay for antibiotic treatment could further enhance cost savings, patient satisfaction, and quality of life. Avoidance of hospitalizations during the COVID-19 pandemic is also a desirable potential benefit for the management of appendicitis using oral rather than intravenous antibiotics.

TRIAL DATA
Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days.
Sippola S, Haijanen J, Grönroos J, et al. Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis: The APPAC II Randomized Clinical Trial. JAMA. Published online January 11, 2021. doi:10.1001/jama.2020.23525