TOPLINE:

In patients with uncomplicated appendicitis, initial antibiotic treatment yielded a true recurrence rate of nearly 38% over 10 years. More than half of the patients treated with antibiotics avoided appendectomy, and they experienced fewer cumulative complications than patients who underwent surgery.

METHODOLOGY:

• This secondary analysis of the APPAC trial aimed to evaluate late recurrence of appendicitis and the appendectomy rate following antibiotic treatment in patients with CT-confirmed uncomplicated acute appendicitis.
• Patients were randomly assigned to either undergo appendectomy (n = 219; median age, 36 years; 61.2% men) or receive antibiotic therapy (n = 253; median age, 33 years; 59.7% men). The antibiotic group received intravenous ertapenem (1 g/d) for 3 days, followed by oral levofloxacin (500 mg once daily) and metronidazole (500 mg thrice daily) for 7 days. All patients were followed up for 10 years.
• The secondary endpoint was overall postintervention complications.

TAKEAWAY:

• At the 10-year follow-up assessment, the true recurrence rate of appendicitis in the antibiotic group was 37.8% (95% CI, 31.6-44.1) and the cumulative appendectomy rate was 44.3% (95% CI, 38.2-50.4).
• Overall complication rates were significantly lower in the antibiotic group than in the surgery group (8.5% vs 27.4%; P < .001).

IN PRACTICE:

"The decision 'to cut or to keep' in the management of acute uncomplicated appendicitis is nuanced and must be individualized, carefully weighing the patient's values, age, and risk tolerance, with a clear understanding of the uncertainties involved," the author of an accompanying editorial wrote.

SOURCE:

This study was led by Paulina Salminen, MD, PhD, Turku University Hospital, Turku, Finland. It was published online on January 21, 2026, in JAMA.

LIMITATIONS:

The study mandated laparoscopic appendectomy for all clinically suspected recurrences, which may have led to an increase in unnecessary surgeries. Additionally, 41 patients in the antibiotic group with intact appendices lacked follow-up MRI, limiting tumour assessment. The use of open appendectomy rather than laparoscopic appendectomy for some patients and a mandatory 3‑day hospitalisation may have affected complication rates, costs, and patient satisfaction.

DISCLOSURES:

This study was supported by the Sigrid Jusélius Foundation and The Academy of Finland. One author reported receiving personal fees from Novo Nordisk, Becton Dickinson, Johnson & Johnson, and GT Metabolic Solutions. Another author reported receiving personal fees from Mehiläinen.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.