Antibiotic Treatment for Appendicitis Successful in First 90 Days for Many

October 7, 2020

By Nancy Melville

YORK, Me -- October 7, 2020 -- Most patients with appendicitis who are treated with antibiotics instead of undergoing an appendectomy do not require surgery within 3 months, and those who do are likely to have an appendicolith, according to a study presented at the 2020 Virtual Meeting of the American College of Surgeons (ACS).

In the Comparison of the Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, 1,552 adults presenting with appendicitis at 25 US centres were randomised 1:1 to receive a 10-day course of antibiotics or an appendectomy, which involved a laparoscopic procedure in 96% of the patients. Of the patients, 414 had appendicolith.

For the primary outcome of 30-day health status, assessed according to the European Quality of Life-5 Dimensions (EQ-5D) questionnaire, treatment with antibiotics was noninferior to treatment with appendectomy (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03).

Among patients in the antibiotic group, 29% underwent appendectomy within 90 days (41% of those who had an appendicolith and 25% of those who did not).

Patients in the antibiotic group had more complications, such as infections and reactions to antibiotics, than those in the appendectomy group (8.1 vs 3.5/100 participants; rate ratio [RR] = 2.28; 95% CI, 1.30-3.98), which may be because of the higher rate of complications in patients with appendicolith in that group (20.2 vs 3.6/100 participants; RR = 5.69; 95% CI, 2.11-15.38).

Patients without an appendicolith in the antibiotic group did not have significantly different complication rates compared with the appendectomy group (3.7 vs 3.5/100 participants; rate ratio, 1.05; 95% CI, 0.45-2.43).

Serious adverse events occurred at a rate of 4.0/100 versus 3.0/100 participants (RR = 1.29; 95% CI, 0.67-2.50) in the antibiotics and appendectomy groups, respectively. Serious adverse events included hospitalisation other than for appendicitis (19/group). In addition, the antibiotic group had 4 unplanned admissions to the intensive care unit, 1 case of septic shock, 1 pulmonary embolism, 1 acute renal failure, and 1 severe antibiotic reaction. The surgery group had 1 case of bleeding requiring transfusion.

Although patients receiving antibiotic treatment missed, on average, 3.4 fewer days of work than those undergoing appendectomy (5.3 vs 8.7 days), they were more likely to need another hospitalisation (24% vs 5%), including for an appendectomy.

Whereas the nearly 30% rate of appendectomy with antibiotics within 90 days may give some surgeons pause, some patients, particularly those with concerns about being treated with surgery during the pandemic, may see it otherwise, according to Giana H. Davidson, MD, University of Washington School of Medicine, Seattle, Washington.

“When you talk to some patients, depending on their personal priorities, health, and concerns, a 7 out of 10 chance that they won’t have to have an operation may be reasonable to them as long as it’s safe,” she said.

The researchers originally intended to report results after a 1-year follow-up. However, with the coronavirus disease 2019 (COVID-19) pandemic resulting in highly increased interest in relieving the burden on healthcare systems, they reported results of a 90-day follow-up.

“When COVID hit, there were recommendations, including from the American College of Surgeons, to restrict time in the operating room to minimise exposure to the virus and reserve personal protective equipment for healthcare providers,” explained Dr. Davidson. “We were getting calls from all over the country asking for our CODA data.”

[Presentation title: A Randomized Trial Comparing Antibiotics and Appendectomy for Appendicitis (CODA)]