Appendicitis: Antibiotics and Surgical Toss Up

Antibiotics were not inferior to appendectomy, depending on their health status with a standard 30-day quality of life score in a randomized open-label trial.

However, 29% of the patents assigned to antibiotics in the Comparison of Antibiotic and Appendectomy Results (CODA) study received appendectomy in 90 days, David R. Flum, MD, of the University of Washington, Seattle. MPH reported.Author In New England Journal of Medicine..

In a practical study of 1,552 patients at 25 centers in the United States, there were negligible significant differences between groups in the main results of the European quality of life-5-dimensional average 30-day score study. Not reported (0.92 for antibiotics vs. 0.91 for immediate appendectomy).

By week 1, resolution of appendicitis symptoms was similar in both groups, with an average discharge time of 1.33 days in the antibiotic group and 1.30 days after surgery after randomization. Those who received antibiotics missed less days of work: an average of 5.26 days compared to 8.73.

However, complications were more than doubled in the drug therapy group and were 3.5 per 8.1 to 100 participants (rate ratio 2.28, 95% CI 1.30-3.98), and emergency department visits were nearly tripled. .. In addition, 11% needed at least one additional course of antibiotics within 90 days.

Similarly, the incidence of serious adverse events was 4.0 in the antibiotic group and 3.0 per 100 participants in the surgery group (incidence 1.29, 95% CI 0.67-2.50). No death occurred.

Flum et al. Prefered that 70% of patients assigned antibiotics would return to work sooner, reduce the burden on caregivers, and focus on avoided surgery.

“These data may be particularly relevant during a COVID-19 pandemic, as patients and clinicians weigh the benefits and risks of each approach, taking into account their individual characteristics, preferences, and circumstances. “The researchers write.

Different from before Randomized controlled trial Among the antibiotics for appendicitis, they added that CODA did not exclude important subgroups such as appendicitis patients.

In this study, patients were evenly randomized to antibiotics or immediate surgery from May 2016 to February 2020. It was continuously adopted by the emergency department diagnosed with acute appendicitis. The average age was about 38 years and 63% were male.

Participants in the drug therapy group received intravenous antibiotics for at least 24 hours, followed by pills for a total of 10 days. Of these patients, 414 had appendiceal stones and 47% were not hospitalized for index treatment. In the surgery group, 96% underwent laparoscopic surgery.

Antibiotic recipients who have undergone appendectomy are at increased risk of complications as defined in the National Surgical Quality Improvement Program, and 41% of antibiotic recipients with this complex function will eventually undergo appendectomy. I received it, but otherwise it was 25%.

In addition, 11% of the antibiotic group had an appendectomy within 48 hours and 20% had an appendectomy by 30 days.

Previous research It points out the same drawbacks as antibiotic therapy for appendicitis.

To Ancillary editorialMPH, MD, MD, Danny Jacobs, MD, Oregon Health & Science University, Portland, said the study was an important contribution to the literature on antibiotic-appendectomy for appendicitis.

However, he did not call it a victory for antibiotics as an initial treatment, and in fact suggested that surgery remained preferred for most clinicians and patients.

Jacobs, who was not involved in the trial, emphasized that all pros and cons of different treatments should be discussed with patients who may prioritize results differently.

“Given that laparoscopic appendicitis is a very effective treatment, it can resolve pain quickly and return the patient to normal activity while avoiding the risk of recurrent appendicitis and hospitalization. I think most healthcare providers would recommend surgical treatment for uncomplicated appendicitis if that option is available, “Jacobs wrote.

In addition, he worried that “vulnerable populations” might be pressured to accept antibiotic treatment “priority or without proper education on long-term effects.”

However, Jacobs agreed that the burden placed on the healthcare facility by the COVID-19 pandemic could, in some cases, upset the balance in favor of non-surgical treatment.

Within the limits of some studies, the authors found that open-label, which may have influenced primary and other outcomes, as well as a 90-day follow-up that hindered the observation of long-term complications and recurrences. Was quoted.

This study may have been prone to selection bias, as only 30% of eligible patients agreed to randomize, and this percentage varied from study site to study site. In addition, the practical design did not specify hospitalization requirements or antibiotic regimens to use.