Appendectomy outperforms antibiotics for pediatric appendicitis
In children with uncomplicated appendicitis, antibiotic-only treatment led to more failures and major complications within one year than appendectomy.
*Systematic review and meta-analysis of randomized trials; Level 1a (OCEBM).

Citation

Faria I, Godinho Cintra AC, Albuquerque Mello de Oliveira LG, et al. Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis: A Systematic Review and Meta-Analysis. JAMA Pediatrics. 2026;180(1):26-34. doi:10.1001/jamapediatrics.2025.4091. Published online October 5, 2025.

Background

Antibiotic-only treatment has been proposed to avoid surgery for uncomplicated appendicitis in children, but durability and serious complications remain concerns. This review summarizes randomized trial evidence comparing antibiotics vs appendectomy.

Patients

Children and adolescents younger than 18 years with uncomplicated acute appendicitis. Excluded: nonrandomized and quasi-randomized studies.

Intervention

Antibiotic-only, nonoperative treatment.

Control

Appendectomy (usually laparoscopic).

Outcome

Treatment failure and success at 1 year (primary); major complications needing another procedure under anesthesia (primary); time to return to school/normal activity (secondary).

Follow-up Period

Up to 12 months (key outcomes reported at 1 year).

Results

Outcome Effect (antibiotics vs appendectomy) Practical meaning
Treatment failure at 1 year (primary) Risk ratio 4.97 (95% CI, 3.57-6.91); absolute failure 36.6% vs 7.0%; number needed to harm ≈4 About 1 extra failure for every 4 treated with antibiotics first.
Treatment success at 1 year (primary) Risk ratio 0.67 (95% CI, 0.60-0.75) Lower chance of being well at 1 year without unplanned surgery or serious problems.
Major complications (primary) Risk ratio 33.37 (95% CI, 7.89-141.05) Serious complications were much more common with antibiotics-first care.
Appendicitis recurrence after antibiotics 18.47 recurrences per 100 children by 1 year Nearly 1 in 5 had appendicitis return within a year.
Return to school 1.36 days faster with antibiotics (mean difference −1.36 days; 95% CI, −2.64 to −0.08) Small early recovery advantage.
No deaths were reported.

Limitations

Trials varied in outcome definitions and follow-up, and some recovery outcomes showed inconsistent results across studies. Early return-to-school benefits were small and may be offset by later readmissions and delayed surgery.

Funding

Not reported; authors reported no conflicts.

Clinical Application

For most children with uncomplicated appendicitis, recommend appendectomy as first-line. Offer antibiotics-first only after shared decision-making about higher failure, recurrence, and major complication risks.