Randomised controlled trialindependent cross-checkabstract checked I-ORG-108 standard review

Antibiotic strategy for simple appendicitis in Dutch children

Non-operative treatment strategy versus surgery for children with simple appendicitis: non-inferiority randomised controlled trial.

Overview

van Amstel P et al.. BMJ Med 2026 · PMID 42157906 · DOI 10.1136/bmjmed-2025-002466

About 70% of children treated with antibiotics avoided an operation, with similar complication rates, but non-inferiority was not proven.

Does the study support the specific claim? Partly · Methodological quality: moderate

Study explained simply

What did the researchers want to find out?: Compare a non-operative strategy with surgery
How was the study done?: Randomised trial
How many people, animals or samples were studied?: 302 children aged 7-17
What was actually found?: Complications 9.3% vs 8.6%; 69.5% avoided surgery
How large was the observed effect?: Risk difference 0.7%
What do the results mean in everyday life?: Antibiotics are a possible option for selected children
What are the study's limitations?: Unblinded, moderate size
What does it say about Elawady's specific claim?: Partly supports avoiding some operations; appendicitis still needs treatment
Do the results apply to Germany and Europe?: Directly applicable
What can explicitly not be concluded from this study?: Cannot show equivalence

Authors: van Amstel P et al.
Journal: BMJ Med
Year: 2026
Identifier: PMID 42157906 DOI 10.1136/bmjmed-2025-002466
Verification: verified – PubMed efetch 2026-10-26; Crossref works API 2026-10-26
Retracted: no
Corrections: none
Extent checked: abstract only
Conflicts of interest and funding: Not stated in abstract.

Is a non-operative strategy non-inferior to appendectomy for complications in children with imaging-confirmed simple appendicitis?

Study design: Randomised controlled trial – Multicentre randomised non-inferiority trial (margin 5%), 1-year follow-up
Population: Children 7-17 years with imaging-confirmed simple appendicitis without faecolith
Country: Netherlands (15 hospitals)
Period: 2017-2023
Sample size: 302 (151 per arm)
Inclusion and exclusion criteria: Imaging-confirmed simple appendicitis; faecolith excluded

Exposure / intervention: IV amoxicillin-clavulanate + gentamicin 48 h, then oral 5 days
Comparator: Appendectomy
Endpoints: Complications within 1 year (primary); appendectomy avoided; HRQoL; costs; satisfaction
Statistical methods: Absolute risk difference with 95% CI

Results: Complications 14/151 (9.3%) vs 13/151 (8.6%) (absolute difference 0.7%, upper 95% limit 7.1%; non-inferiority not proven). Appendectomy avoided in 105/151 (69.5%). HRQoL similar. Costs lower with non-operative strategy; longer hospital stay (3.3 vs 1.9 days) and lower satisfaction (Net Promoter Score 18.9 vs 48.0).
Absolute risks: Complications 9.3% vs 8.6%; 69.5% avoided surgery.
Authors' conclusion: Non-inferiority not proven, though most of the CI lay within the margin; about 70% avoided surgery; similar HRQoL, lower costs, longer stay and lower satisfaction.

Risk difference reproduced (stats/C-ORG-17_appendicitis.py); CI -5.8% to 7.1% crosses the 5% margin.

Shows that most children with simple appendicitis can avoid surgery with antibiotics.

St Peter 2025 found inferiority with a different failure definition.

Dutch; directly applicable.

Partly supports the claim that many appendectomies in children could be avoided, but within a supervised antibiotic treatment strategy.

Multidimensional assessment
Multidimensional assessment
Authenticity of the source	verified
Methodological quality	moderate
Risk of bias	some concerns
Precision of results	moderate
Directness	direct
Reproducibility	partly replicated
Consistency with the overall evidence	mixed
Regional transferability	high
Adequacy of the interpretation (by the archive)	not applicable

Long-term recurrence.