Antibiotics noninferior to appendectomy for appendicitis

Treating appendicitis with antibiotics first may be a feasible alternative to appendectomy, suggests the CODA* trial which reflect noninferiority of antibiotics to appendectomy.

“Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis,” said the researchers. However, despite considerable evidence supporting its benefit in this setting, appendectomy remains the standard treatment for appendicitis. [Br J Surg 2009;96:473-481; Lancet 2011;377:1573-1579; JAMA 2015;313:2340-2348;Br Med J 1956;2:1458-1461]

In CODA, mean 30-day EQ-5D** scores were similar between the antibiotic and the appendectomy arms (0.92 vs 0.91 points; mean difference, 0.01 points). [N Engl J Med 2020;383:1907-1919]

At 90 days, 29 percent of patients on antibiotics had undergone appendectomy. “[This translates to] about three in 10 patients in the antibiotic group ultimately undergoing an appendectomy within 90 days,” said coprincipal investigator Dr David Flum from the University of Washington School of Medicine, Seattle, Washington, US, in a press release.

Although this implies a higher incidence of emergency department visits among antibiotic recipients following index treatment, an alternative perspective is that, >70 percent were still able to avoid surgery, explained Flum and colleagues.

NSQIP***-defined complications were more frequent with antibiotics vs appendectomy (8.1 vs 3.5/100 participants; rate ratio [RR], 2.28), which may be attributed to patients with vs without appendicolith (20.2 vs 3.6/100 participants; RR, 5.69). Nonetheless, serious adverse event rates were similar between arms (4 vs 3/100 participants; RR, 1.29), as were the rates of complications among patients without appendicolith (3.7 vs 3.5/100 participants; RR, 1.05).

“In terms of overall health status, antibiotics were no worse than surgery and allowed most people to avoid an operation in the short term,” noted coprincipal investigator Dr David Talan from the David Geffen School of Medicine at the University of California, Los Angeles, California, US.

Medical vs surgical?

Based on previous evidence, experts noted that the choice between medical and surgical management should involve shared decision-making and reflect a relative determination of value and preference. [Br J Surg 2016;103:656-667; J Trauma Acute Care Surg 2017;82:1129-1137] “[B]ecause patients may appropriately prioritize different outcomes, the pros and cons of all treatment options should be presented and discussed,” noted editorialist Dr Danny Jacobs from Oregon Health and Science University, Portland, Oregon, US.

The largest randomized trial to assess appendicitis treatment, CODA randomized 1,552 patients 1:1 to receive antibiotics (IV for at least 24 hours followed by a 10-day oral course) or undergo appendectomy. Of these, 414 had appendicoliths. Nearly half (47 percent) of antibiotic recipients were treated at the emergency department only and were not hospitalized for index treatment. Ninety-six percent of appendectomy procedures were done laparoscopically.

“CODA … is really the first of its kind to capture these measures for shared decision-making about appendicitis,” noted CODA Patient Advisory Chair Bonnie Bizzell, in a press release. “Information like this can be important for individuals as they consider the best treatment option for their unique circumstance.”

“There were advantages and disadvantages to each treatment, and patients will value these differently based on their unique characteristics, concerns, and perspectives,” Flum said.

Surgery in the time of COVID-19

The COVID-19 pandemic has driven health systems and organizations to modify methods of delivering patient care. The ACS^# recommended that hospitals and surgery centres should consider patient needs and informed preferences, potential risks incurred by operation delays, resource availability and capacity, and safety. [www.facs.org/covid-19/clinical-guidance/elective-case/emergency-surgery, accessed December 23, 2020]

“These data may be particularly relevant during the COVID-19 pandemic, as patients and clinicians weigh the benefits and risks of each approach, considering individual characteristics, preferences, and circumstances,” said the researchers.

“[The] advantages of antibiotic treatment relative to surgery may be greater during the COVID-19 pandemic or other public health emergencies in which operating room capacity and other resources are severely constrained,” said Jacobs.

However, the short follow-up may have underrepresented data on recurrence and long-term complications, hence the need for further explorations with longer term follow-up.