Is there a case for using antibiotics instead of surgery for acute appendicitis?

When an adult patient presents in the emergency department with acute uncomplicated appendicitis, is nonsurgical treatment with antibiotics appropriate for some patients? It’s a question that has sparked several randomized clinical trials over the past decade, but patient inclusion criteria differed in the trials. This prompted European researchers to perform a meta-analysis of six randomized trials, published in the Lancet Gastroenterology and Hepatology in March 2025. It included 2,101 patients with image-confirmed acute appendectomy, equally assigned to antibiotics and appendicectomy. After one year of follow-up, 33.9% of the patients in the antibiotics group had an appendicectomy. The World Society of Emergency Surgery (WSES) provided guidelines on diagnosis and treatment of acute appendicitis, published in January 2026 JAMA Surgery. The consensus panel behind the guidelines included Canadian surgeons. The recommendation states that antibiotics are an alternative in the treatment of adults with uncomplicated acute appendicitis, “provided there is appropriate clinical management and shared decision-making.” The recommendation is conditional, supported by moderate certainty of evidence.Other guidelines lean to the surgical route. A Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline published in 2024 (before the Lancet meta-analysis) recommended managing uncomplicated appendicitis surgically instead of using antibiotics alone. The recommendation was conditional, which “signals the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty,” the paper notes. The recommendation echoes those made in Canadian Association of General Surgeons’ 2018 dynamic guidelines for emergency surgery.Having an appendicolith (sometimes called a fecalith) detected in pre-intervention imaging impacted the outcome for those treated with nonoperative antibiotics in the Lancet Gastroenterology and Hepatology meta-analysis. Patients who had an appendicolith in the antibiotics group had more complications than those with an appendicolith in the appendicectomy group. More patients who had an appendicolith in the antibiotic group underwent an appendicectomy at one year (48.7%) than those who did not have an appendicolith (30.6%).The WSES guidelines note that while appendicolith is a risk factor for perforation, it’s not considered a criteria for labelling appendicitis as complicated. Finnish researchers who studied a large patient cohort noted that appendicolith was correlated with a risk of complicated appendicitis. Their 2024 study was published in BMJ Open.There’s also the question of how and where the antibiotics are delivered in patients being treated without surgery. The WSES guidelines suggest outpatient management. In the trials, patients receiving antibiotics get intravenous infusions for at least 24 hours, and may stay longer in the hospital for monitoring. In a 2021 paper in CMAJ, Dr. Ameer Farooq, Dr. Francois Rouleau-Fournier and Dr. Carl Brown from the University of British Columbia outline when antibiotics may be a suitable treatment choice for patients. In that paper, released before the Lancet meta-analysis, they outline the common IV regimen. The WSES guidelines suggest a follow-up of 30 days following nonoperative management with antibiotics, but do not recommend routine follow-up beyond that. Follow-up depends on the patient. It notes that careful monitoring may be difficult in low-resource setting.Researchers from the University of Virginia wrote a clinical review of The Lancet Gastroenterology and Hepatology meta-analysis, recently published in the American Journal of Emergency Medicine. Their conclusion was that antibiotic therapy may be a reasonable initial management strategy for adults with uncomplicated acute appendicitis, as long as patients understand the risks. They also suggest caution when treating patients with an appendicolith because of an increased risk of complications and future surgery.

Is there a case for using antibiotics instead of surgery for acute appendicitis?

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