EXECUTIVE SUMMARY

Antibiotics instead of surgery is a reasonable approach for some patients with early uncomplicated appendicitis, according to the authors of a recent study; however, it is not the standard of care. To reduce legal risks, EPs considering this practice should:

  • direct the patient to consult with a surgeon for recommended treatment;
  • inform the patient of the risks of refusing an evaluation by the surgeon and/or refusing surgery;
  • consider offering antibiotics as an alternative if patients refuse surgery.

Antibiotics instead of surgery is a reasonable approach for patients with early uncomplicated appendicitis, according to the authors of a recent small pilot study.1 Of 30 patients, 16 were randomized to antibiotics first and 14 underwent an appendectomy. Participants in the antibiotics group were discharged only after at least six hours of observation in the ED, with next-day follow-up.

Some key findings include the following:

  • Of the 15 antibiotic-treated adults, 14 were discharged from the ED and all demonstrated symptom resolution;
  • At the one-month mark, major complications had occurred in two appendectomy patients;
  • Antibiotics-first patients experienced less hospital time than appendectomy patients as well as less pain and disability;
  • At the one-year mark, two of the 15 patients treated with antibiotics had developed appendicitis. One was successfully treated with antibiotics, and one underwent an appendectomy.

However, virtually no EPs in the United States have experience with this approach, according to David Talan, MD, FACEP, FIDSA, who led the study. A previous paper found that one-fifth of Irish surgeons routinely treated uncomplicated appendicitis with antibiotics.2

“Most practice experience is from Northern Europe rather than the U.S.,” notes Talan, chair emeritus of the department of emergency medicine and faculty in the division of infectious diseases at Olive View-UCLA Medical Center in Sylmar, CA.

In the ED setting, the EP would first advise the patient with suspected appendicitis to allow a surgeon to evaluate him or her, Talan says. If the surgeon concurs that the patient has appendicitis, the surgeon would guide treatment options. Most will recommend an appendectomy.

“But there are surgeons in the world, and even a minority in this country, who offer antibiotics to patients,” Talan notes. “And those providers are often the ones who have experience doing it.”

Next Best Alternative

Talan says that a similar approach is used routinely for ED patients with uncomplicated diverticulitis who are discharged with antibiotics with next-day follow-up. A growing number of providers, though not in the ED setting, are taking the same approach with appendicitis patients.

“Some offer it as an equal alternative to surgery. Some offer it as a secondary alternative, describing it as something new that appears to be safe,” Talan explains.

EDs might consider this approach if appendicitis patients refuse surgery. It’s a rare occurrence, but it does happen, Talan says.

“There are certainly circumstances when even when the surgeon is called, and we talk with the patient and say they need surgery, they refuse,” Talan reports.

In such cases, the EP is obligated to inform the patient of the risks of refusing an evaluation by the surgeon and/or refusing surgery.

“But you also have an obligation to treat them with the next best alternative,” Talan adds. “That would be antibiotics.”

If the EP has no prior experience with this approach, the patient ideally would remain under observation in the hospital. On the other hand, the patient might request to be treated with antibiotics and go home, and is well enough to be discharged. “There’s certainly enough evidence that the EP can do that, and that the patient would be fine,” Talan offers.

In more than 1,700 patients with uncomplicated appendicitis treated with antibiotics and described in 21 published studies, none has gone on to develop diffuse peritonitis or severe sepsis, and no patient has died, Talan adds. Some patients are adamant that they don’t want surgery; others may have heard of the option of antibiotics.

“The patient has the right to direct their care. This is safe in the right patients and in experienced hands,” Talan says.

The study’s findings pave the way for a multicenter U.S. trial comparing antibiotics first to appendectomy. The authors of the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial will enroll and randomize 1,600 patients with early appendicitis to surgery or antibiotics.3 The study will shed light on long-term outcomes and which patients are likely to experience better outcomes with either antibiotics or surgery.

“We know that it’s safe. We are now going to see how this plays out in different centers and in different types of patients,” says Talan, co-principle investigator of the trial. Ken Zafren, MD, FAAEM, FACEP, clinical professor of emergency medicine at Stanford University Medical Center, says, “For EPs, nonoperative antibiotic treatment of appendicitis is neither standard care, nor should it be viewed as standard of care.” Zafren adds that asking a surgeon to see the patient and provide treatment, either with an appendectomy or with antibiotics, would likely prevent legal exposure for the EP. If a patient with uncomplicated appendicitis refuses to see the surgeon, Zafren would recommend as a next best alternative:

  • treating the patient with antibiotics with a period of observation in the ED (if the patient agrees);
  • documenting that the patient refused to see the surgeon;
  • discharging the patient against medical advice (AMA). This process includes giving the patient an open invitation to return to the ED at any time, instructing the patient to obtain close follow-up, and specifically warning the patient to return to the ED for any worsening of the condition, or if there is not marked improvement by the next day.

“It is probably not legally defensible for the EP to give antibiotics as an alternative to surgery without consulting a surgeon,” Zafren cautions.

In previous studies, patients treated with antibiotics were hospitalized, Zafren notes.

“The multicenter CODA trial may be large enough to show whether the approach is safe — and to confirm or change current practice by EPs,” he adds.

REFERENCES

  1. Talan DA, Saltzman DJ, Mower WR, et al. Antibiotics-first versus surgery for appendicitis: A U.S. pilot randomized controlled trial allowing outpatient antibiotic management. Ann Emerg Med 2017;70:1-11.
  2. Kelly ME, Khan A, Ur Rehman J, et al. A national evaluation of the conservative management of uncomplicated acute appendicitis: How common is this and what are the issues? Dig Surg 2015;32:325-330.
  3. Davidson GH, Flum DR, Talan DA, et al. Comparison of outcomes of antibiotic drugs and appendectomy (CODA) trial: a protocol for the pragmatic randomised study of appendicitis. BMJ Open 2017;7:e016117.

SOURCES

  • David Talan, MD, FACEP, FIDSA, Chair Emeritus, Department of Emergency Medicine; Faculty, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA. Phone: (818) 364-3107. Email: dtalan@ucla.edu.
  • Ken Zafren, MD, FAAEM, FACEP, Alaska Native Medical Center, Anchorage, AK; Stanford University Medical Center, Stanford, CA. Phone: (907) 346-2333. Email: kenzafren@gmail.com.