J

O
U
R
N
A
L
Preceptor: dr. Iman
R
Permana, M. Kes
Wahyu Wijayanto
E
A Yuda Arie Dharmawan
Destha Alissa
D
I Hannisa Hafiz
N M. Rizki Mussafa
G Siti Novita Kuman
1 5/15/17
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BACKGROUND

Appendicitis is common infection that occur in abdomen.

Appendicectomy has been the mainstay for the treatment for

acute appendicitis

The advent of laparoscopic surgery and the low threshold for

operative intervention have led to a risk of high negative
appendicectomy rates with unnecessary surgery related
morbidity.

Antibiotic treatment was often considered as a bridge to surgery

in patients with suspected appendicitis but no clear indications for
appendicectomy such as signs of perforation or peritonitis. Less
morbidity associated with antibiotic treatment than surgery in5/15/17
uncomplicated acute appendicitis
3
OBJECTIVE

To compare the
safety and efficacy
of antibiotics versus
appendicectomy for
treatment of
uncomplicated acute
appendicitis 5/15/17
4
METHOD

Inclusion
Criteria

RCTs comparing antibiotic treatment with appendicectomy

for uncomplicated acute appendicitis in adult patients

RCTs with well defined diagnostic and treatment protocols

which reported at least two of the outcome measures
(complications, treatmet efficacy, length of stay,
readmissions) published between January 1996 December
2011 5/15/17
5

Exclusion
Criteria

Non-randomised studies, retrospective

studies, case series studies

Studies that reported outcomes in patients

with complicated appendicitis (local or
contained perforation with an appendicular
abscess or mass). 5/15/17
6
Assesing the methodological
quality of the RCTs using
method of randomisation,
concealment of allocation,
blinding, description of
dropouts and withdrawals,
intention to treat analysis,
and duration of follow-up.
METHOD
Evaluation for methodological
quality of the RCTs and to rate
the quality of evidence and
strength of recommendations
of the meta-analysis using
GRADE (the grading of
recommendations
assessment, development,
and evaluation ) system, as
recommended by the
5/15/17
Cochrane Collaboration.
7

The GRADE system

assess the RCTs across
five main domains for Accordingly, the
each outcome:
limitations of the study recommendation for
design and execution; either antibiotic
inconsistency, treatment or
indirectness, and appendicectomy was
imprecision of results; graded as very low,
and publication bias. low, moderate, or
high.

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Outcome Measure

The secondary outcome

measures were efficacy of
The primary outcome treatment, length of stay,
measure was complications. and incidence of complicated
appendicitis and
readmissions.

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Outcome Measure

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Data Collection &
Statistical Analysis

The meta analysis was done using Review Manager version 5.1
software

Mantel-Haenszel method was used to combine the summary statistic

and assessed the statistical heterogeneity by using the I2 method
alongside the 2 P value.

Random effect model was used to provide a conservative estimate of

the results.

We considered the results to be statistically significant at the P<0.05

level if the 95% confidence interval did not include the value .
5/15/17
11
Result
Four randomised
controlled trials with a
Antibiotic treatment was
total of 900 patients
associated with a 63%
(470 antibiotic
(277/438) success rate
treatment, 430
at one year.
appendicectomy) met
the inclusion criteria.

There is a relative risk

reduction of 31% for
antibiotic treatment
No significant
compared with
differences were seen for
appendicectomy (risk
treatment efficacy or
ratio 0.69 (95%
length of stay.
confidence interval 0.54
to 0.89); I2=0%; 5/15/17
12
Table 1. Summary of outcome

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 Table 2. GRADE analysis: antibiotics versus
13 appendicetomy for uncomplicated acute
appendicitisquality assessment

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14
Limitations of the Study

The major
confounders that
may have had an
influence on the
outcomes are:

Planned
Type and duration discharge after
Diagnosis of Reporting of
of antibiotic either antibiotic
appendicitis complications,
treatment treatment or
appendicectomy.

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15
CONCLUSION

Antibiotics can be used

safely as primary
treatment in patients
presenting with acute
uncomplicated
appendicitis
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 CRITICAL APPRAISAL

The validity Interpretati Applicabilit

of the on of the y of the
research result result
I. EVALUATION OF THE VALIDITY
OF THE REVIEW

1. Is the clinical question clearly focused

with regard to:
the population?

Yes people with acute uncomplicated appendicitis

the intervention?

Yes antibiotics versus appendicectomy

the outcome measures?

Yes complications, length of stay, readmissions,

treatment efficacy
2. Are the criteria for the selection of the
studies to be included in the review in
accordance with:
the specifications of the foregoing question in regard to
populations, interventions, and results?

Yes
the type of research design that will be chosen?

Yes RCT
3. Is the literature search method clearly
specified?
Yes the authors used the search strategy

developed by the Cochrane Collaboration Group

Is there a high probability that some

relevant studies may have been omitted?
No
4. Have the identified studies been
evaluated for methodological quality?
Yes GRADE system: systematic assessments of all RCTs
across five main domains for each outcome: limitations of
the study design and execution; inconsistency,
indirectness, and imprecision of results; and publication
bias
5. Was the methodological quality
evaluation carried out by more than one
person independently, and the degree of
agreement between them established?
Yes the 1st & 2nd author search and evaluate the
sources of the meta analysis; any disagreements were
resolved by discussion with the 3rd author
 II. INTERPRETATION OF THE RESULTS OF
THE REVIEW

1. Were the results consistent from one

study to another?
Yes
2. What were the overall results of the
review?
Antibiotic therapy relative risk reduction of
31% (risk ratio 0.69); no significant
differences in treatment efficacy or length of
stay.
3. How precise were the results?
95% CI 0.54 0.89, p=0.004
 III. APPLICABILITY OF THE RESULTS OF THE
REVIEW IN CLINICAL PRACTICE

1. Are my patients similar to the patients included

in the original studies? Yes
2. Is the intervention feasible in my setting? Yes
3. Have all the clinically relevant results been
taken into consideration? Yes
4. Do the benefits outweigh the potential harm?
Yes
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