Jurnal :

Antibiotics as First-line Therapy for Acute Appendicitis: Evidencefor a Change in Clinical PracticeJeanette Hansson Ulla Korner Karin LudwigsErik Johnsson Claes Jonsson Kent LundholmPublished online: 9 May 2012Societe Internationale de Chirurgie 2012Nurul Mazni Abdullah112012230Pembimbing: dr Romzi K. spB

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Abstract Background : Randomized studies have indicated that acute appendicitis may be treated by antibiotics without the need of surgery. However, concerns have been raised about selection bias of patients in such studies. Therefore, the present study was aimed to validate previous findings in randomized studies by a full-scale population-based application.Methods : All patients with acute appendicitis at Sahlgrenska University Hospital (May 2009 and February 2010) were offered intravenous piperacillin plus tazobactam according to our previous experience, followed by 9 days out-hospital oral ciprofloxacin + metronidazole. Endpoints were treatment efficacy and complications. Efficient antibiotic treatment was defined as recovery without the need of surgery beyond 1 year of follow-up.

Results : A total of 558 consecutive patients were hospitalized and treated due to acute appendicitis. 79%(n=442) received antibiotics as first-line therapy and 20 % (n=111) had primary surgery as the secondline therapy. 77% of patients on primary antibiotics recovered while 23 % (n=100) had subsequent appendectomy due to failed initial treatment on antibiotics. 38 patients (11 %) of the 342 had experienced recurrent appendicitis at 1-year follow-up. Primary antibiotic treatment had fewer complications compared to primary surgery. Conclusions: This population-based study confirms previous results of randomized studies. Antibiotic treatment can be offered as the first-line therapy to a majority of unselected patients with acute appendicitis without medical drawbacks other than the unknown risk for long-term relapse, which must be weighed against the unpredicted but well-known risk for serious major complications following surgical intervention.

PendahuluanAppendisitis akut adalah kelainan surgikal tersering4 randomized controlled trials telah dilakukan bagi membandingkan antibiotika dengan appendektomi menunjukkan hasil yang sama 88-95% initial recovery pada terapi antibiotikRekurensi pada penelitian sebelumnya 10-15% setelah 1 tahun pasien diterapi dengan antibiotik + komplikasi mayor < (abses, reoperasi, obstruksi usus halus)Studi yang pertama pada pasien 18-50 tahun, hanya 20% pasien yang layak validitas dan generalitas rendah

MetodeProspective nonrandomized population-based study

Material Subjek : 558 pasien dirawat ec appendisitis akut. (0.10-0.12% dari populasi 575000-600000)Prestudy 18% perforasi, 82% nonperforasi pada operasiKriteria inklusi :dewasa >16 tahun dengan appendisitis akut berdasarkan anamnesa, status abdominal, tes laboratorium, pemeriksaan radiologi (jika meragukan), mendapat antibiotika sebagai terapi lini pertamaKriteria eksklusi : Pasien yang diterapi di luar

Waktu : May 2009 and February 2010Lokasi : surgical clinics of Sahlgrenska University Hospital/Sahlgrenska and Sahlgrenska University Hospital/Ostra

Intervensi Antibiotik diberi sebagai terapi lini pertama, namun tergantung ahli bedah apakah perlunya dioperasi atau APSGagal terapi antibiotik dilihat dariProgression status abdomenPeningkatan suhu tubuhTidak ada pembaikan dalam 12-24 jamMereka yang hamil atau appendisitis rekuren appendektomiPiperracillin +tazobactam 4g/8 jam minimal 3 dosis dalam 24 jam. Nir oral + cairan intravena. Status klinis >> (> 12-24 jam) pulang + antibiotik (ciproflxacin 500mg dan metronidazole 400mg 2x/hari) sebagai tambahan untuk 9 hari

Pengumpulan dataData pre, peri dan post-terapi dicatat berdasar protokolAhli bedah menilai status abdominal dan alasan untuk operasi bila perluQuestionnaires - gejala sisa dan sakit perut, pengalaman dirawat di rumah sakit sebelumnya, apa saja operasi atau pengobatan relevan tambahan didapatData medis rumah sakit bagi tiap pasien dicari minimum 1 tahun setelah terapi dan dicari apakah adanya komplikasi, rekurensi dan reoperasi

Analisis statistikTes chi square perbedaan antara proporsit-test membandingkan variable antara kelompok psuccess primary antibiotics. The most common complications among operated patients were prolonged postoperative course (vomiting, intestinal paralysis) and wound infection, and among antibiotics-treated patients, the most common complication was some side effect of the antibiotics (mainly diarrhea).

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Patient experienceAbdominal discomfort after 6 and 12 months did not differ between the antibiotics and the surgery group after 12 months 27 % abdominal symptom(+)Based on questionnaire answers from 411(74 %) patients at 6 months 382 (69 %) patients at 12 months. The proportion that answered the questionnaire was similar in both groups

Duration of antibiotic therapyFirst-line antibiotics = intravenous antibiotic (primary surgery with subsequent perioperative antibiotics) (1.60.2 days). Primary antibiotics failure appendectomy 2.30.1 days compared to those who recovered on primary antibiotics alone, as expected (p\0.001).

Hospital stayPrimary antibiotics (2.3 0.1 days) primary antibiotics alone(1.9 0.1 days; p\0.001)

Diskusi >75% pasien dengan appendisitis akut sembuh dengan terapi antibiotika tanpa perlunya operasiAmoxicillin dan asam klavulanat cukup untuk infeksi GITJuga tidak ada perbedaan signifikan pada komplikasi mayor pada pasien yang pulih sepenuhnya dengan antibiotika primer dan mereka yang mendapat appendektomi rescue seterusnya Komplikasi minor 2x lebih banyak pada pasien yang mendapat operasi primer dan proporsi pasien yang mengalami abdominal discomfort antar 6-12 bulan tidak berbedaKebanyakan pasien dewasa boleh diterapi awal dengan antibiotik pada 12-36 jam pertama tanpa ada persoalan untuk operasi akut seperti generalized peritonitis, sepsis sistemik dan tanda disfungsi vital lain

Kesimpulan Studi population-based mengkonfirmasi hasil randomized studies sebelumnya. Terapi antibiotika sebagai terapi lini pertama boleh diberikan pada mayoritas pasien appendisitis akut tanpa medical drawbacks selain dari risiko yang diketahui untuk relaps jangka lama, yang harus dipertimbang dengan risiko komplikasi mayor yang tidak dapat diprediksi tapi sedia diketahui setelah intervensi bedah

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