Can Children With Uncomplicated Acute Appendicitis Be Treated With Antibiotics Instead of an Appendectomy? Jennifer A. Horst, MD; Indi Trehan, MD, MPH; Brad W. Warner, MD; Brian G. Cohn, MD* *Corresponding Author. E-mail: cohnb@wusm.wustl.edu, Twitter: @emjclub. 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2015.01.025 [Ann Emerg Med. 2015;-:1-4.] Editor’s note: Emergency physicians must often make decisions about patient management without clear-cut data of sufficient quality to support clinical guidelines or evidence-based reviews. Topics in the Best Available Evidence section must be relevant to emergency physicians, are formally peer reviewed, and must have a sufficient literature base to draw a reasonable conclusion but not such a large literature base that a traditional “evidence-based” review, meta-analysis, or systematic review can be performed. Emergency physicians must often make decisions about patient management without clear-cut data of sufficient quality to support clinical guidelines or evidence-based reviews. Topics in the Best Available Evidence section must be relevant to emergency physicians, are formally peer reviewed, and must have a sufficient literature base to draw a reasonable conclusion but not such a large literature base that a traditional “evidence-based” review, meta-analysis, or systematic review can be performed. INTRODUCTION Acute appendicitis is a frequent indication for pediatric surgical consultation in the emergency department, where the criterion standard of treatment is appendectomy. However, operative management involves the risks of surgical complications and exposure to general anesthesia, in addition to a potentially lengthy recovery time. One meta-analysis of complications after laparoscopic and open appendectomy for nonperforated appendicitis in children found complication rates of 2.6% and 2.7%, respectively, 1 whereas another found rates of 5.7% and 2.6%. 2 Although these complication rates are low, surgery can be associated with significant time off of school for children and of work for their parents. Nonoperative management of uncomplicated appendicitis may thus offer a number of theoretical advantages. Several case series, 3-6 prospective randomized studies, 7-10 and meta-analyses 1,11-14 have suggested that antibiotic treatment without interval appendectomy may be sufficient therapy for uncomplicated appendicitis in adults. A Cochrane Review concluded that surgery remained the criterion standard, although the authors conceded that “nonoperative management may be used as an alternative in a good quality RCT [randomized controlled trial] or in specific patients or conditions where surgery is contraindicated,” because of the low to moderate quality of the studies reviewed. 15 A recent meta-analysis revealed a success rate of 63% at 1 year for nonoperative management, with no difference in the incidence of complicated appendicitis. 12 Given this experience in adult patients, the effectiveness of a nonoperative, antibiotics-only approach to the management of acute uncomplicated appendicitis in children is reviewed here. SEARCH STRATEGY Two authors (J.A.H. and B.G.C.) independently searched EMBASE and MEDLINE, using the terms “(nonoperative or non-operative) AND appendicitis AND children,” resulting in 75 and 66 citations, respectively. Relevant studies involving children with uncomplicated, nonperforated acute appendicitis were selected for inclusion. A total of 4 relevant articles were identified. Review of the bibliographies of these articles revealed no further relevant studies. ARTICLE SUMMARIES Abes et al 16 This retrospective chart review from Turkey evaluated children admitted for appendicitis who were initially managed nonoperatively. The diagnosis of appendicitis was made according to history, physical examination result, WBC count, and ultrasonographic findings demonstrating Volume -, no. - : - 2015 Annals of Emergency Medicine 1 PEDIATRICS/BEST AVAILABLE EVIDENCE