At first glance, the results of a recent meta-analysis published in JAMA Pediatrics would indicate immediately operating on a child is the most effective treatment for uncomplicated acute appendicitis. But researchers and other experts say patients and families may appreciate the chance to avoid hospitalization with antibiotic treatment.

A growing body of evidence suggests antibiotics can be a viable first step for many children. While nonoperative management carries a higher risk for recurrence and later appendectomy, patients often recover faster and avoid hospitalization. Experts stress “success” is not purely clinical; it depends on each family’s priorities, from minimizing interventions to returning to daily life sooner — making individualized decision-making central to care.

“It’s not just about comparing success rates; it’s about defining what success means for each family, whether that’s minimizing interventions, avoiding anesthesia, or achieving the lowest chance of readmission,” said Isabella Faria, MD, surgery resident at The University of Texas Medical Branch in Galveston, Texas, and the lead author of the meta-analysis.

For the meta-analysis, Faria and her colleagues identified seven randomized controlled trials comparing nonsurgical and surgical management of uncomplicated acute appendicitis, with a study population of 1480 children.

Nonoperative management was associated with higher rates of recurrence and need for a later appendectomy than immediate surgery.

One in five children in the antibiotics group ended up needing surgery within 48 hours or a year, and major complications were significantly more common. Readmission rates were also higher in the nonoperative group (risk ratio, 9.86; 95% CI, 2.29-42.35; P  = .002).

But patients who received antibiotics returned to school a mean of 1.36 days earlier and to normal activities a mean of 4.93 days earlier than the surgical group (P values = .04 and .01, respectively).

A Complicated Landscape

Growing interest in treating pediatric appendicitis with antibiotics — spurred by studies over the past three decades suggesting mediation management could safely replace surgery — has also fueled doubt over which option is best for patients, said Ravi S. Radhakrishnan, MD, pediatric surgeon at The University of Texas Medical Branch, who helped the author of the study.

“As clinical enthusiasm grew, so did uncertainty,” Radhakrishnan said.

Not all studies of nonoperative management use consistent definitions of treatment success, and follow-up times were often limited, he said.

The results of the meta-analysis by Faria and colleagues were dominated by one of the most recent studies, published in January 2025, accounting for about 60% of patients overall. In this trial, children randomized to nonoperative treatment who did not improve on antibiotics by the second day of treatment had appendectomy.

Other investigations of nonoperative appendicitis management have allowed longer antibiotic trials, said David Talan, MD, emergency medicine physician and professor of emergency medicine and infectious diseases at the University of California in Los Angeles, who was not involved in the meta-analysis.

For example, another study published in 2020 in JAMA found two thirds of children with uncomplicated appendicitis who were treated with antibiotics did not require appendectomies 1 year later. Another trial published in the New England Journal of Medicine, for which Talan was a coauthor, showed that 40% of patients randomized to antibiotic treatment had surgery within 1 year, and 46% had surgery within 2 years.

Although the authors classified later appendectomy as a failure of antibiotic therapy, the point is that surgery can often be avoided for many patients, Talan said.

Many patients and families may not want to have an unnecessary surgery and should have the choice to try antibiotics knowing that there may be a more than 60% chance their child will not need surgery, said Peter Minneci, MD, who authored the 2020 study. A 2021 survey of more than 1200 adults found most would choose nonoperative management of appendicitis initially, even if the chance of eventual surgery was more than 50%.

The new meta-analysis confirms this success rate for medication management and also shows that patients can return to activities significantly faster than those who have immediate surgery, Talan said.

Notably, the new meta-analysis defined failure of management with antibiotics and undergoing an appendectomy as a complication.

“I would not consider that a complication of nonoperative management, because nonoperative management is a strategy of treating with antibiotics, and if you do not improve clinically, you then move on to surgery, so that is not a complication,” Minneci said.

Talan also said that many of the trials included in the new meta-analysis were not blinded. Many clinicians, he said, err on the side of immediate surgery.

“The authors do not comment on the potential asymmetrical bias brought by surgeons and participants based on practice inertia and the now-disproven 100-year-old notion that, without its emergency removal, the appendix will burst and be fatal,” he said. “This notion has led to many premature surgeries and underestimated” the efficacy of management with antibiotics.

Faria and colleagues received no outside funding for their study, and the researchers reported having no financial conflicts of interest.

Talan and Minneci reported having no financial conflicts of interest.