Antibiotics versus Appendectomy for Acute Appendicitis — Longer-Term Outcomes

Collaborative, Coda; Davidson, Giana H.; Flum, David R.; Monsell, Sarah E.; Kao, Lillian S.; Voldal, Emily C; Heagerty, Patrick J.; Fannon, Erin; Lavallee, Danielle C.; Bizzell, Bonnie; Lawrence, Sarah O.; Comstock, Bryan A.; Krishnadasan, Anusha; Winchell, Robert J.; Self, Wesley H.; Thompson, Callie M; Farjah, Farhood; Park, Pauline K.; Alam, Hasan B.; Saltzman, Darin J.; Moran, Gregory J.; Kaji, Amy H.; DeUgarte, Daniel A.; Salzberg, Matthew; Ferrigno, Lisa; Mandell, Katherine; Price, Thea P.; Siparsky, Nicole; Glaser, Jacob; Ayoung-Chee, Patricia; Chiang, William K.; Victory, Jesse; Chung, Bruce; Carter, Damien; Kutcher, Matthew; Jones, Alan E.; Holihan, Julie L.; Liang, Mike K.; Faine, Brett; Cuschieri, Joseph; Evans, Heather L.; Johnson, Jeffrey; Patton, Joe H.; Coleman, Natasha; Fischkoff, Katherine; Drake, Frederick Thurston; Parsons, Charles S.; Odom, Stephen R.; Kessler, Larry G.; Talan, David A.

doi:10.1056/nejmc2116018

Cited by 39 publications

(39 citation statements)

References 4 publications

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“…Eight RCTs met the inclusion criteria 4 , 5 , 9–11 , 21–23 . For one study 22 , data were also extracted from a secondary publication 24 that provided longer-term follow-up. The characteristics of these studies are described in Table 1 , and the reasons for exclusion of ineligible studies that had undergone full-text review 25–35 are listed in Table S2 .…”

Section: Resultsmentioning

confidence: 99%

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

2022

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Background This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis. Methods A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented. Results Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. −0.05 to 0.35)). Conclusions Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.

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Section: Resultsmentioning

confidence: 99%

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

2022

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“…There is, however, a substantial risk of needing a subsequent appendectomy with antibiotic treatment, and appendectomy was in the CODA collaborative study performed in 11% of the participants in 48 h, in 20% by 30 days, and in 29% by 90 days [ 33 ]. Long-term follow up showed that the percentage of patients who underwent subsequent appendectomy was 40% after 2 years [ 35 ]. This is consistent with earlier findings that approximately 60% of adult patients with acute uncomplicated appendicitis can be treated successfully with antibiotics [ 4 ].…”

Section: Resultsmentioning

confidence: 99%

“…The APPAC trial [ 36 ] failed to establish the non-inferiority of antibiotic treatment, but conservative management is still considered a safe treatment option in patients with verified uncomplicated appendicitis [ 10 , 35 , 37 ]. However, there is a considerable proportion (up to 40%) of the patients treated conservatively that will later need an appendectomy, and the patients should be informed of this.…”

Section: Resultsmentioning

confidence: 99%

The Diagnostic Differentiation Challenge in Acute Appendicitis: How to Distinguish between Uncomplicated and Complicated Appendicitis in Adults

Skjold-Ødegaard

Søreide

2022

Diagnostics

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(1) Background: How to best define, diagnose and differentiate uncomplicated from complicated acute appendicitis remains debated. Hence, the aim of this review was to present an overview of the current knowledge and emerging field of acute appendicitis with a focus on the diagnostic differentiation of severity currently subject to ongoing investigations. (2) Methods: We conducted a PubMed search using the MeSH terms “appendicitis AND severity” and “appendicitis AND classification”, with a focus on studies calling appendicitis as ‘uncomplicated’ or ‘complicated’. An emphasis on the last 5 years was stressed, with further studies selected for their contribution to the theme. Further studies were retrieved from identified full-text articles and included per the authors’ discretion. (3) Results: The assumption that appendicitis invariably will proceed to perforation has been outdated. Both uncomplicated and complicated appendicitis exist with likely different pathophysiology. Hence, this makes it important to differentiate disease severity. Clinicians must diagnose appendicitis, but, in the next step, also differentiate between uncomplicated and complicated appendicitis in order to allow for management decisions. Diagnostic accuracy without supportive imaging is around 75–80% and, based on clinical judgement and blood tests alone, the negative appendectomy rate has been described as high as 36%. More research is needed on available biomarkers, and the routine use of imaging still remains debated. Scoring systems have the potential to improve diagnostic accuracy, but no scoring system has yet been validated for differentiating disease severity. Currently, no universally agreed definition exists on what constitutes a complicated appendicitis. (4) Conclusions: Uncomplicated and complicated appendicitis appear to have different pathophysiology and should be treated differently. The differentiation between uncomplicated and complicated appendicitis remains a diagnostic challenge.

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“…This implies that half the patients could well avoid surgery for 4 years with conservative management, avoiding potentially unnecessary surgery. The American College of Surgeons has also henceforth updated their treatment guidelines for appendicitis to include antibiotics as an accepted first-line treatment [ 7 ].…”

Section: Discussionmentioning

confidence: 99%

Conservative antibiotic treatment of pediatric acute uncomplicated appendicitis during the COVID-19 pandemic: a prospective comparative cohort study

et al. 2022

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Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic management versus laparoscopic appendectomy for acute uncomplicated appendicitis (AUA) in children during the COVID-19 pandemic when resources were limited and transmission risks uncertain. Method In this prospective comparative cohort study, we analyzed the data of 139 children diagnosed with AUA meeting the following inclusion criteria: 5–18 years of age, symptoms duration of ≤ 48 h, appendix diameter ≤ 11 mm and no appendicolith. Treatment outcomes between non-operative management group (78/139) and upfront laparoscopic appendectomy group (61/139) were compared. Antibiotic regimes were intravenous ceftriaxone/metronidazole or amoxicillin/clavulanic acid for 48 h, followed by oral antibiotics to complete total 10-days course. Results 8/78 (10.3%) children had early failure (within 48 h) requiring appendectomy. 17/70 (24.3%) patients experienced late recurrence within mean follow-up time of 16.2 ± 4.7 months. There were no statistical differences in peri-operative complications, negative appendicectomy rate, and incidence of perforation and hospitalization duration between antibiotic and surgical treatment groups. Cost per patient in upfront surgical group was significantly higher ($6208.5 ± 5284.0) than antibiotic group ($3588.6 ± 3829.8; p = 0.001). Conclusion Despite 24.3% risk of recurrence of appendicitis in 16.2 ± 4.7 months, antibiotic therapy for AUA appears to be a safe and cost-effective alternative to upfront appendectomy.

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Antibiotics versus Appendectomy for Acute Appendicitis — Longer-Term Outcomes

Cited by 39 publications

References 4 publications

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis

The Diagnostic Differentiation Challenge in Acute Appendicitis: How to Distinguish between Uncomplicated and Complicated Appendicitis in Adults

Conservative antibiotic treatment of pediatric acute uncomplicated appendicitis during the COVID-19 pandemic: a prospective comparative cohort study

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