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Acute Appendicitis: Should We Pick Antibiotics or Appendectomy?

Survey findings show short-term benefits may not translate to long-term optimal outcomes.

Appendectomies are a common surgical intervention for appendicitis. It’s estimated that in Northern America, there were 378,614 performed in 2015 and a rough pooled estimate of 100 per 100,000 person years. With such a common condition, alternative treatment options are always being discussed.

The traditional treatment for appendicitis has been surgery, which requires hospitalization and additional expenses for the patient. Any surgery though, can also put the patient at risk for surgical site infections, especially if there is an existing infection. Such surgeries require additional health care resources and ultimately, put the patient at risk. Perhaps, it’s time to re-evaluate our existing approach to acute appendicitis. In addition to studying the use of alternative methods, what are the longer-term outcomes?

A new correspondence letter to the editor within The New England Journal of Medicine sought to address this possibility—was there a different in outcomes and longer-term outcomes of appendicitis treated with antibiotics versus surgical intervention? Within a comparison of outcomes of antibiotic drugs and appendectomy (CODA) trial, researchers reviewed short-term outcomes across 1552 patients with appendicitis.

The research team noted that “found that antibiotic treatment was noninferior to appendectomy on the basis of a measure of general health status at 30 days, with similar rates of safety events. Among the patients in the antibiotics group, 29% had undergone appendectomy by 90 days (41% with an appendicolith vs. 25% without).”

Having collected data for one year after recruitment, they surveyed individuals about their outcomes. Interestingly, those in the antibiotic group had some fascinating findings: 40% underwent a subsequent appendectomy and at 3-4 years that increased to 49%. Those patients who had a history of an appendicolith were more likely to have an appendectomy, with a hazards ratio of 2.9 within 48 hours and 1.4 from 48 hours to 30 days.

The authors noted that “After 30 days, complications were uncommon in the two treatment groups, regardless of the presence or absence of an appendicolith (Table S3). Among patients with recurrence in the antibiotics group, perforation was reported in 20% (95% CI, 13 to 28), a percentage that was similar to that in the appendectomy group (16%; 95% CI, 13 to 19). Among patients with 2-year follow-up, 62 of 443 (14%) in the antibiotics group had received an additional course of antibiotics; of these patients, 66% underwent subsequent appendectomy.”

As the authors noted, consideration should be also made for patient preference as many prefer an antibiotic course as a first-line attempt at management of appendicitis. Future research should focus on various treatments and non-surgical interventions for appendicitis, with close attention to near and longer-term outcomes. Awareness for patient sentiments is also an important dynamic that should be considered. As appendicitis impacts hundreds of thousands of people a year, establishing a wider variety of efficacious treatment options is recommended.