Optimizing Antibiotic Therapy for Complicated Appendicitis: A Systematic Review of Short versus Prolonged Courses

J Surg Res. 2025 Dec:316:26-37. doi: 10.1016/j.jss.2025.10.008. Epub 2025 Nov 20.

Abstract

Introduction: Complicated appendicitis often requires postoperative antibiotics, yet the ideal duration remains unclear. Prolonged use may increase risks without added benefits. This study aimed to determine whether short-course antibiotics (≤5 d) are as effective and safe as longer courses in patients undergoing appendectomy for complicated appendicitis.

Methods: We searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library from inception through April 2025. Randomized controlled trials and cohort studies comparing short versus prolonged postoperative antibiotic duration were included. Primary outcomes were intra-abdominal abscess, surgical site infection, mortality, readmission, reoperation, and hospital length of stay. The DerSimonian and Laird random-effects model was used for meta-analysis.

Results: Thirteen studies with a total of 5325 patients were included. No statistically significant variations were found between the groups in intra-abdominal abscess (odds ratio [OR] = 0.967; 95% confidence interval [CI]: 0.770-1.236; P = 0.838), surgical site infection (OR = 0.983; 95% CI: 0.677-1.425; P = 0.929), mortality (OR = 1.315; 95% CI: 0.269-6.419; P = 0.735), or readmission (OR = 1.046; 95% CI: 0.620-1.765; P = 0.867). However, the short-course group showed a significantly shorter hospital stay (mean difference = -1.907 d; 95% CI: -3.302 to -0.512; P = 0.007).

Conclusions: Short-course postoperative antibiotic therapy is safe and noninferior to longer regimens for complicated appendicitis. It significantly reduces hospital length of stay and may lower antibiotic-related complications. Standardizing short-course protocols can improve patient outcomes and support global antibiotic stewardship.

Keywords: Appendectomy; Complicated appendicitis; Intra-abdominal abscess; Meta-analysis; Postoperative antibiotics; Short-course therapy; Surgical site infection.

Publication types

  • Systematic Review
  • Meta-Analysis
  • Comparative Study

MeSH terms

  • Abdominal Abscess / epidemiology
  • Abdominal Abscess / etiology
  • Abdominal Abscess / prevention & control
  • Anti-Bacterial Agents* / administration & dosage
  • Anti-Bacterial Agents* / adverse effects
  • Appendectomy* / adverse effects
  • Appendicitis* / complications
  • Appendicitis* / mortality
  • Appendicitis* / surgery
  • Drug Administration Schedule
  • Humans
  • Length of Stay / statistics & numerical data
  • Patient Readmission / statistics & numerical data
  • Postoperative Care* / adverse effects
  • Postoperative Care* / methods
  • Postoperative Care* / standards
  • Randomized Controlled Trials as Topic
  • Surgical Wound Infection* / epidemiology
  • Surgical Wound Infection* / etiology
  • Surgical Wound Infection* / prevention & control
  • Treatment Outcome

Substances

  • Anti-Bacterial Agents