Antibiotics instead of surgery for appendicitis: a second opinion

An opinion piece by Dr Pieter Marais, Specialist Surgeon

In January 2026 the World Society of Emergency Surgery published its updated Jerusalem Guidelines on acute appendicitis in JAMA Surgery. Among the recommendations is one that has travelled fast and far: for selected patients with uncomplicated appendicitis, antibiotics alone are a reasonable alternative to an operation.

That recommendation is real, it is evidence-based, and I follow the guideline. But I want to say something slightly unfashionable: in South African practice, the antibiotics-first idea is being oversold. Not by the guideline itself, which is careful and conditional. By the way it gets summarised.

What the guideline actually says

A guideline is not a rule. It is a group of specialists reading every good study available up to a cut-off date and grading how confident the evidence lets them be. The Jerusalem Guidelines label most of their recommendations conditional — meaning "we suggest", not "we recommend". Antibiotics-only treatment of uncomplicated appendicitis is one of those conditional suggestions, and it comes with three conditions attached: the appendicitis must be uncomplicated, the patient must have reliable follow-up and access to care, and the decision must be shared with a properly informed patient.

Those three conditions are where the argument lives.

The number that keeps me operating

The guideline puts the recurrence rate after antibiotics-only treatment at 15 to 20 percent. Most of those recurrences happen within the first year.

One in five or six is not a footnote. And a recurrence does not politely schedule itself. It arrives on a Sunday night, on holiday in Ballito, three days before a matric exam, or in the middle of a work trip — away from the surgeon who knows the history and the hospital where the file sits. The patient who avoided one planned operation now faces an unplanned one, under worse circumstances, sometimes with a more inflamed appendix than the first time.

"Reliable follow-up" is doing a lot of work in that sentence

The studies behind antibiotics-first were largely done in systems where a patient can be reviewed within days, imaged quickly, and readmitted without friction. I would not describe that as the universal South African experience.

In practice I see patients who live an hour from the hospital, who cannot easily take a second week off work, whose medical aid authorisation for a second admission is a negotiation, and who — entirely reasonably — interpret "you can try antibiotics" as "this is fixed". Safety-netting only works if the net is actually there. Where it is not, choosing the treatment with a one-in-five failure rate is not the conservative option. It is the riskier one dressed as caution.

The cost argument usually runs the other way

Antibiotics are often framed as the cheaper, gentler path. Count the whole pathway, though: an initial admission with intravenous antibiotics, a course of tablets, follow-up visits, then in a meaningful minority a second presentation, repeat imaging, a second admission and an appendicectomy anyway — frequently a more difficult one.

A single laparoscopic appendicectomy in a stable patient is a short, well-established operation. Most patients go home the next day and are back at a desk within a week or two. It ends the problem once.

And there is the appendix nobody looked at

This is the point I would most want a patient to hear. The guideline notes that in patients aged 35 and older presenting with an appendiceal abscess, up to 14 percent have an underlying tumour of the appendix.

If the appendix is never removed, it is never sent to the laboratory, and nothing is ever examined under a microscope. In an older patient that is not a small omission. It is also why the guideline is firm about colonoscopy and interval surgery in that group — a recommendation I would not treat as optional.

When antibiotics are genuinely the right call

I am not arguing against non-operative management. I use it. It is the right choice when:

• imaging confirms genuinely uncomplicated appendicitis — inflammation without perforation, gangrene or abscess;
• the patient is a poor candidate for anaesthesia or surgery for other medical reasons;
• the patient lives close to care, has quick access to me or to a hospital, and understands exactly what to watch for;
• and the patient, fully informed of the recurrence rate, chooses it.

Children are a specific case: initial non-operative management is acceptable, and the guideline advises against routine interval appendicectomy in children afterwards.

When I recommend surgery

• Complicated appendicitis — perforation, gangrene, abscess or peritonitis. This is not a debate.
• Diagnostic uncertainty, particularly in older patients where a tumour has to be excluded.
• Patients whose access to follow-up care is unreliable, or who will be travelling or otherwise far from help.
• Patients who simply want it dealt with definitively — a legitimate preference, not an unsophisticated one.

One more point of agreement with the guideline, and one that surprises people: a stable patient does not need a middle-of-the-night operation. Appendicectomy within 24 hours of admission is safe. Being scheduled for the morning list, with a rested team, is better care than being wheeled in at 02:00.

The bottom line

Antibiotics-first for appendicitis is a real option that belongs in the conversation. My concern is that it gets repeated as "you don't need surgery for appendicitis any more", which is not what the evidence says and not what serves patients here.

The honest version is longer: for some carefully selected patients, in the right circumstances, with clear plans for what happens if the pain returns, antibiotics are reasonable — and one in five will be back. For most patients I see, one laparoscopic operation is still the better trade.

This is my view, informed by the guideline and by what I see in theatre. Your own case may point the other way, and that is a conversation to have with your surgeon. If you are dealing with sudden abdominal pain, do not wait it out at home — appendicitis remains the most common surgical emergency in the world, and time matters. You can contact my rooms to arrange an assessment.

Source: WSES 2025 Jerusalem Guidelines for the diagnosis and treatment of acute appendicitis, JAMA Surgery 2026;161(3):283–295, published online 28 January 2026. This article is general information and is not a substitute for individual medical advice.