负负得正？

An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated appendicitis. A trial assessing the feasibility of nonoperative management for uncomplicated acute appendicitis in children using either IV piperacillin-tazobactam or ciprofloxacin metronidazole therapy for at least 24 hours followed by oral antibiotics for 10 days revealed that 90% of children managed nonoperatively had no progression within 30 days. Another trial among patients with CT-proven, uncomplicated appendicitis revealed that antibiotic treatment did not meet the prescribed criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-yr follow-up period, and those who required appendectomy did not experience significant complications. A 5-yr follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial revealed that among patients who were initially treated with antibiotics for uncomplicated acute appendicitis, the likelihood of late recurrence within 5 yr was 39.1%. It remains to be determined whether the benefits of potentially avoiding an operation with antibiotics-first approach are outweighed by the burden to the patient related to future appendicitis episodes, more days of antibiotic therapy, lingering symptoms, and uncertainty that may affect quality of life.

l 越来越多的证据支持在无并发症的阑尾炎患者中使用抗生素代替手术治疗。一项评估儿童无并发症急性阑尾炎使用哌拉西林-他唑巴坦或环丙沙星甲硝唑静脉注射治疗至少24小时，然后口服抗生素10天的非手术治疗可行性的试验显示：90%的行非手术治疗的儿童在30天内没有进展1。另一项对经CT证实的无并发症的阑尾炎患者的试验显示，与阑尾切除术相比，抗生素治疗并不能满足非劣于规定的标准。大多数随机接受抗生素治疗的无并发症阑尾炎患者在1年随访期内不需要阑尾切除术，那些需要阑尾切除术的患者也没有出现明显的并发症2。在APPAC随机临床试验中，对无并发症急性阑尾炎的抗生素治疗进行的5年随访显示，在最初用抗生素治疗无并发症急性阑尾炎的患者中，5年内晚期复发的可能性为39.1%3。仍有待确定的是，是否抗生素治疗避免可能的手术的益处超过了将来的阑尾炎发作、症状持续以及可能影响生活质量的不确定性给患者带来的负担4。

抗生素治疗并不能满足非劣于规定的标准——那不就是差了吗？