By Joseph E. Scherger, MD, MPH

Core Faculty, Eisenhower Health Family Medicine, Residency Program, Eisenhower Health Center, La Quinta, CA; Clinical Professor, Keck School of Medicine, University of Southern California, Los Angeles

Dr. Scherger reports no financial relationships relevant to this field of study.

SYNOPSIS: A multicenter, randomized trial showed that 10 days of antibiotics results in comparable outcomes as surgery. Three in 10 patients treated with antibiotics required surgery within 90 days.

SOURCE: 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.

Researchers randomized 1,552 adults from 25 centers in the United States to receive 10 days of antibiotics or surgery for acute appendicitis. In the group treated with antibiotics, 47% were not hospitalized.

The antibiotics varied and were selected from the Surgical Infection Society and the Infectious Diseases Society of America guidelines for intra-abdominal infections.1,2 The first dose of antibiotics were given in the ED. These included cefoxitin, moxifloxacin, and ticarcillin-clavulanic acid. In some cases, the authors used dual antibiotics. Outpatient regimens included metronidazole with clindamycin.

In the antibiotics group, 41% of those with an appendicolith went to surgery within 90 days compared with 29% who did not exhibit this finding. There were more complications in the antibiotics group, but those were seen mostly in patients with an appendicolith.


The standard treatment for acute appendicitis has been surgery. Laparoscopy is the most common surgical technique for this condition today. However, like all medical procedures, risk exists.

Using antibiotics to treat appendicitis was first reported more than 60 years ago.3 Since then, investigators have performed other randomized studies of treating appendicitis with antibiotics.4,5 However, this work by the CODA Collaborative is the largest and the first to separate patients with an appendicolith. Although this work is promising, the author of an accompanying editorial urged clinicians to take a cautious approach.6


  1. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt) 2010;11:79-109.
  2. Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt) 2017;18:1-76.
  3. Coldrey E. Treatment of acute appendicitis. Br Med J 1956;2:1458-1461.
  4. Eriksson S, Granström L. Randomized controlled trial of appendectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995;82:166-169.
  5. Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA 2015;313:2340-2348.
  6. Jacob D. Antibiotics for appendicitis — proceed with caution. N Engl J Med 2020;383:1985-1986.