Appendicitis Treatments: Large Randomized Controlled Trial Compares Antibiotics With Appendectomy

Appendicitis Treatments: Large Randomized Controlled Trial Compares Antibiotics With Appendectomy

Douglas K. Rex, MD, MASGE, reviewing CODA Collaborative; Flum DR, et al. N Engl J Med 2020 Nov 12.

Antibiotic treatment is now widely recognized as an option for appendicitis therapy.

In a nonblinded randomized trial of 1552 adults, including 414 with an appendicolith, there was no difference in the primary outcome of 30-day health status on a quality-of-life measure between antibiotics and appendectomy. Patients were excluded for septic shock, peritonitis, recurrent appendicitis, perforation, severe phlegmon or walled-off abscess, or evidence of neoplasm on imaging. Patients in the antibiotics arm were administered antibiotics intravenously for 24 hours, for which 51% were hospitalized at least briefly.

In the antibiotics group, appendectomy was performed in 11% of the patients by 48 hours, 20% by 30 days, and 29% by 90 days. Those with an appendicolith in the antibiotics arm were more likely than patients without an appendicolith to need appendectomy (41% vs 25%). After the index treatment, patients in the antibiotics arm were more likely than patients in the appendectomy group to visit the emergency department (9% vs 4%) and more likely to be hospitalized (including for eventual appendectomy; 24% vs 5%). Among the other outcomes, the antibiotics group missed fewer workdays (5.26 vs 8.73), and neoplasms were found more often in the appendectomy group (7 vs 2). 

Complications occurred in 8.1% of the antibiotics group versus 3.5% of the appendectomy group, attributable to those with an appendicolith (20.2% vs 3.6%) and not to those without an appendicolith (3.7% vs 3.5%). Subcutaneous drains were also needed more often in the antibiotics group than the appendectomy group (2.5% vs 0.5%).

Douglas K. Rex, MD, FASGE

COMMENT

These results could be interpreted to suggest that antibiotics are an option in acute appendicitis, with advice that antibiotics give a 70% chance of avoiding surgery. An appendicolith seen on imaging favors appendectomy. There is a low but real risk of missing appendiceal cancer in those who choose antibiotics.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

CITATION(S)

CODA Collaborative; Flum DR, Davidson GH, Monsell SE, et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med 2020;383:1907-1919. (https://doi.org/10.1056/nejmoa2014320)

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