THE EFFICACY OF ANTIBIOTICS IN ACUTE APPENDICITIS TREATMENT : A COMPREHENSIVE SYSTEMATIC REVIEW

Background: Acute appendicitis has been the most common cause of lower abdominal pain leading to emergency visits worldwide. To avoid major complications, appendectomy has remained the standard treatment for uncomplicated acute appendicitis for over a century. The aim: The aim of this study to show about the efficacy of antibiotics in acute appendicitis treatment. Methods: By the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of the requirements. This search approach, publications that came out between 2014 and 2024 were taken into account. Several different online reference sources, like Pubmed, SagePub, and Sciencedirect were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: Five publications were found to be directly related to our ongoing systematic examination after a rigorous three-level screening approach. Subsequently, a comprehensive analysis of the complete text was conducted, and additional scrutiny was given to these articles. Conclusion: The therapeutic effects of antibiotics and appendicectomy were comparable for the treatment of acute appendicitis.


INTRODUCTION
Acute appendicitis is inflammation of the vermiform appendix and remains the most common cause of the acute abdomen in young adults.The mainstay of treatment in most centres is an appendectomy, and, consequently, this is one of the most common operations performed on the acute abdomen.However, appendicitis can be notoriously difficult to diagnose, and there exists a negative appendectomy rate of 10%-20% despite the use of preoperative computed tomography (CT).In addition, as with all operations, postoperative complications exist, including wound infections, intra-abdominal abscesses, ileus and, in the longer term, adhesions.With this in mind, it is worth considering that the mainstay of treatment for other intra-abdominal inflammatory processes, such as diverticulitis, consists initially of conservative management with antibiotics. 1,2ute appendicitis with the incidence of approximate 1/1000 person-years, which affect 8 million annually, is the most common reason for emergency abdominal surgery.The etiology of acute appendicitis is generally fecal residue or lymphoid tissue proliferation blocking the appendiceal lumen, resulting in high pressure in the lumen and damage to the integrity of the mucosa.Acute appendicitis is classified as either uncomplicated or complicated acute appendicitis.Though the definition of them varies among studies, generally the uncomplicated acute appendicitis may absence of perforation, abscess or peritonitis and may or may not include non-perforated gangrenous or a fecalith. 3nservative treatment with antibiotics is an alternative choice for appendicitis; although the risk of failure is about 13% higher, but the risk of complications is lower.For instance, the odds of overall complications, bowel obstruction, and reoperation were 0.24 (95%CI: 0.13 to 0.44), 0.35 (95%CI: 0.17 to 0.71), and 0.17 (95%CI: 0.04 to 0.75) respectively, when compared to appendectomy.In addition, management might be more cost-effective with antibiotics than appendectomy. 4e perforation rate of 25% in patients with a history of pain of less than 24 h is not much lower than the 35% rate of perforation in patients with a history of over 48 h.These may indicate that uncomplicated and complicated appendicitis are distinct diseases.An alternative outcome is that the appendix becomes surrounded by a mass of omentum which walls the inflammatory process and prevents inflammation from spreading to the abdominal cavity (appendix mass), yet the resolution of the condition is delayed.If the appendix becomes walled off by the omentum but has perforated, an abscess will develop localized to the periappendiceal region in the right paracolic gutter or the subcecal area of the pelvis.However, there is no evidence to indicate the proportion of patients likely to develop diffuse sepsis because the antibiotic treatment alters the pattern of disease by replacing the risks of perforation with the lesser risk associated with surgery. 5 addition, there is interindividual variation between the host (patient) defense mechanisms and the disease.The indications for operative (surgery), nonoperative (antibiotics), or both in management are discussed.Laparoscopic appendicectomy has become the gold standard of treatment, but nonoperative management with antibiotics may suffice in selected cases with uncomplicated appendicitis.The management of the appendix mass/abscess may entail an expedient appendicectomy or a combination of conservative management and interval appendicectomy. 5

METHODS Protocol
By following the rules provided by Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, the author of this study made certain that it was up to par with the requirements.This is done to ensure that the conclusions drawn from the inquiry are accurate.

Criteria for Eligibility
For the purpose of this literature review, we compare and contrast the efficacy of antibiotics in acute appendicitis treatment.It is possible to accomplish this by researching of the efficacy of antibiotics in acute appendicitis treatment.As the primary purpose of this piece of writing, demonstrating the relevance of the difficulties that have been identified will take place throughout its entirety.
In order for researchers to take part in the study, it was necessary for them to fulfil the following requirements: 1) The paper needs to be written in English, and it needs to determine about the efficacy of antibiotics in acute appendicitis treatment.In order for the manuscript to be considered for publication, it needs to meet both of these requirements.2) The studied papers include several that were published after 2014, but before the time period that this systematic review deems to be relevant.Examples of studies that are not permitted include editorials, submissions that do not have a DOI, review articles that have already been published, and entries that are essentially identical to journal papers that have already been published.

Search Strategy
We used " the efficacy of antibiotics in acute appendicitis treatment."as keywords.The search for studies to be included in the systematic review was carried out using the PubMed, SagePub, and Sciencedirect databases by inputting the words: (("Appendicitis"[MeSH Subheading] OR "Antibiotics"[All Fields] OR "Efficacy" [All Fields]) AND ("management"[All Fields] OR " Treatment"[All Fields]) AND ("Teraphy"[All Fields]) OR ("Outcomes" [All Fields])) used in searching the literature.

Data retrieval
After reading the abstract and the title of each study, the writers performed an examination to determine whether or not the study satisfied the inclusion criteria.The writers then decided which previous research they wanted to utilise as sources for their article and selected those studies.After looking at a number of different research, which all seemed to point to the same trend, this conclusion was drawn.All submissions need to be written in English and cannot have been seen anywhere else.

Figure 1. Article search flowchart
Only those papers that were able to satisfy all of the inclusion criteria were taken into consideration for the systematic review.This reduces the number of results to only those that are pertinent to the search.We do not take into consideration the conclusions of any study that does not satisfy our requirements.After this, the findings of the research will be analysed in great detail.The following pieces of information were uncovered as a result of the inquiry that was carried out for the purpose of this study: names, authors, publication dates, location, study activities, and parameters.
for inclusion in the review because they match the criteria set forth for that purpose in the review.After that, we'll determine which articles to include in the review depending on the findings that we've uncovered.This criteria is utilised in the process of selecting papers for further assessment.in order to simplify the process as much as feasible when selecting papers to evaluate.Which earlier investigations were carried out, and what elements of those studies made it appropriate to include them in the review, are being discussed here.

RESULT
Using reputable resources like Science Direct, PubMed, and SagePub, our research team first gathered 3388 publications.A thorough three-level screening strategy was used to identify only five papers as directly relevant to our ongoing systematic evaluation.Next, a thorough study of the entire text and further examination of these articles were selected.showed conservative management is no doubt gaining ground, and a lot of centers are inclined towards non-operative management; therefore, further randomized controlled trials and meta-analyses should be carried out on the matter for a more conclusive verdict.
Picard,C et al (2023) 7 showed NOT with a narrowed antibiotic therapy using amoxicillin-clavulanic acid appears to be an effective alternative to surgical intervention for AUA in children with regard to local bacteriological epidemiology.Narrowed antibiotic therapy by amoxicillin/clavulanic acid presents satisfactory results and limits the risk of developing antibiotic resistance compared with antibiotics with a broader spectrum.Our results also lead us to conclude that this treatment does not induce a risk of aggravation or complications for the patients.These results should be confirmed by larger studies.
Salminen, P et al (2022) 8 showed the lack of antibiotic superiority statistically suggests that a non-inferiority trial against placebo is warranted in adults with CT-confirmed mild appendicitis.CODA (2020) 9 showed for the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure.In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days.Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.
Steiner, Zvi et al (2018) 10 showed the feasibility and safety of conservative management of AUA in children.A rigorous diagnostic plan with strict inclusion and exclusion criteria was used, leading to an approximately 85% success rate of CAT instead of appendectomy.The CAT does not compete with surgery or make appendectomy obsolete.It is a safe alternative in selected suitable cases and can spare appendectomy.

DISCUSSION
Acute appendicitis is the most common cause of abdominal pain in emergency departments.The lifetime risk of acute appendicitis in males is 8.6 and 6.7% in females with recent meta-analysis showing an increasing trend in the incidence of appendicitis in the newly industrialised countries.Appendectomy has unquestionably been the standard treatment for acute appendicitis for over a century with more than 300.000 appendectomies performed annually in the United States.Although appendectomy is generally well tolerated, it is a major surgical intervention and can be associated with postoperative morbidity.Recently, an increasing amount of evidence has been reported showing that the majority of patients with uncomplicated acute appendicitis may be treated with antibiotics alone instead of surgery. 8,11ute appendicitis is a clinical diagnosis based on history, physical examination, laboratory investigations, and imaging.The diagnosis is established in approximately 90% of patients presenting with classic symptoms of appendicitis, which include migratory pain to the right lower quadrant, vague periumbilical pain, low-grade fever, anorexia, nausea, and vomiting.Although historically appendicectomy is the goal standard treatment for acute appendicitis, recently, there has been a marked increase in using broad-spectrum antibiotics as a safe primary approach for patients with uncomplicated acute appendicitis who wish to avoid surgery and the potential postoperative complications. 12 is widely believed that acute appendicitis always results in perforation.This belief has persisted since Fitz's initial explanation of the connection between McBurney's report on reduced death from pelvic infections following an appendectomy, and the appendix that an urgent appendectomy is required upon appendicitis diagnosis stems from this line of reasoning.Fitz and McCurney were published 40 years before antibiotics were widely accessible.Minimal invasive treatment is effective and safe, as demonstrated in several randomized clinical trials (RCTs), with a success rate ranging from 63-85%.Such trials have been the subject of meta-analyses and thorough reviews, with positive results.However, because children have unique anatomical and pathophysiologic characteristics, the clinical picture of acute appendicitis in pediatric patients differs from that in adults, making treatment choices for children more challenging. 13,14ficacy rates were higher in the appendectomy group.Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up.Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin.Complications were more frequent and significant in the surgery group.These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism.Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. 15ring the 1950s, an initial non-operative approach for acute appendicitis was attempted, but it was not generally accepted at the time.Appendicitis complicated by appendicular abscess/phlegmon may be managed with antibiotics and nonoperative strategies with reduced complication rates compared to surgery, like other acute inflammatory intestinal conditions -i.e.diverticulitis and enterocolitis.In this sense, antibiotic therapy may be associated with reduced costs of treatment, avoiding operation and its consequent complications.However, the use of antibiotics alone as primary therapy for uncomplicated acute appendicitis is still being assessed, and studies have shown conflicting results so far. 12

CONCLUSION
In conclusion, the therapeutic effects of antibiotics and appendicectomy were comparable for the treatment of acute appendicitis.Therefore, we recommend that more individuals are considered for antibiotic therapy instead of surgery.