- Using antibiotics alone to treat children with uncomplicated appendicitis came with higher risks of treatment failure and serious complications within a year compared with appendectomy.
- Researchers reported a treatment failure rate of 36.6% at 1 year in patients who were treated with nonoperative management, compared to 7.0% for those who underwent surgery.
- The findings from the meta-analysis contrast with a 2017 pediatric study that supported antibiotics as a safe primary option.
Children with acute uncomplicated appendicitis (UA) treated with antibiotics alone faced significantly higher risks of treatment failure and serious complications within a year compared with those who underwent appendectomy, according to a meta-analysis.
The review pooled data from seven trials involving nearly 1,500 children. Nonoperative management (NOM) with antibiotics led to a 36.6% treatment failure rate at 1 year versus 7.0% for surgery (RR 4.97, 95% CI 3.57-6.91, I²=0.0%).
Major complications requiring intervention (Clavien-Dindo grade ≥IIIb) also were far more common with NOM (RR 33.37, 95% CI 7.89-141.05, I²=9.5%), reported Isabella Faria, MD, of the University of Texas Medical Branch in Galveston, and colleagues in JAMA Pediatrics.
The findings contrast with a 2017 pediatric meta-analysis that supported antibiotics as a safe primary option, which the authors noted was based on limited patient numbers and reliance on cohort studies that increased bias.
"What we're seeing now is that, as the volume and quality of evidence increase, a clearer signal is emerging: nonoperative management is associated with higher failure rates and more complications," Faria told MedPage Today in an email. "This does not contradict prior research. It builds on it and helps us understand where nonoperative management might not be as safe or effective as once hoped."
"While antibiotic treatment is still a safe option for pediatric patients, knowing the high chances of having to come back to the [emergency department] or for an operation within a year will help guide parents and physicians to a more informed decision," she added.
The findings should not be used to pick a winner in the debate between treatment options, cautioned Shawn Rangel, MD, MSCE, of Boston Children's Hospital and Harvard Medical School, in an accompanying editorial. Such framing, he said, "risks oversimplifying the complexity of this decision and overstating the certainty of what the evidence can provide."
Reported NOM failure rates in individual trials ranged from about 18% to 37%, a wide range likely to spark confusion, he wrote.
"The more pragmatic interpretation of existing data is that [surgery] and NOM both represent evidence-based options, and that the challenge is no longer to prove one is superior to the other but to provide families with transparent, pathway-specific data to guide decisions that align with their values, lifestyle, and tolerance for risk," Rangel wrote.
Similarly, the authors pointed out that while NOM is associated with higher recurrence and reintervention rates, "these outcomes alone do not determine the optimal approach for every patient." Rather, their analysis allows for trade-offs -- for example, durability versus early recovery, or surgical risk versus avoidance.
"Both operative and nonoperative approaches are valid in the treatment of pediatric UA, and the choice should take into account family values, local expertise, and the evolving evidence base," they wrote. "This nuanced understanding reinforces the importance of shared decision-making at the bedside, where individualized priorities must guide treatment selection."
One observed benefit of NOM was a modestly quicker recovery: Children treated with antibiotics returned to school 1.36 days sooner on average than those who had surgery (95% CI -2.64 to -0.08, P=0.04) and returned to normal activities 4.93 days earlier (95% CI -8.68 to -1.19, P=0.01).
But those gains may be offset by recurrent disease. Recurrence occurred in 17.39% of NOM patients overall (95% CI 12.08-23.38, I²=52.7%), including 18.47% at 1 year (95% CI 12.62-25.07, I²=48.5%).
"Even if your child starts with antibiotics, there's still a real chance they'll need surgery later, often urgently, and sometimes with added complications that would otherwise not be present when the kid first presented with acute uncomplicated appendicitis at the first visit," co-author Ana Carolina Godinho Cintra, of Federal University of Bahia in Salvador, Brazil, told MedPage Today in an email.
The overall rate of complications was also higher with NOM (RR 2.98. 95% CI 1.82-4.87, P=0.001), though rates of mild and moderate complications did not differ. The excess came from severe events.
Researchers identified 1,246 studies via searches of PubMed, Embase, Scopus, Cochrane, and Web of Science, then screened them to assess eligibility. The final analysis included seven randomized controlled trials conducted between 2015 and 2025, involving 1,480 pediatric patients, ages 3-17 years. The largest of those was a 2025 randomized non-inferiority trial that involved nearly 850 children and found treatment failure at 12 months occurred in 34% of those who received antibiotics compared with 7% of those who underwent appendectomy.
Faria's group emphasized that the trial sequential analysis confirmed the robustness of the main outcomes. Still, study limitations included the variability in the follow-up periods, outcome definitions, and reliance on composite measures.
Faria and co-authors, as well as Rangel, disclosed no relationships with industry.
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