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TURKU, FINLAND – Here’s some useful information for emergency physicians trying to decide whether to send uncomplicated appendicitis patients home with antibiotics or to a surgeon.
A new study finds that most patients with uncomplicated appendicitis did not require an appendectomy when treated with antibiotics, and those who eventually needed to undergo surgery did not experience significant complications.
Antibiotic treatment did not meet a pre-specified level of effectiveness compared with appendectomy, however, according to the study published recently in the Journal of the American Medical Association.
For the study, researchers from Turku University Hospital in Finland randomly assigned 530 patients with uncomplicated acute appendicitis confirmed by a computed tomography [CT] scan to receive antibiotic therapy for 10 days or a standard appendectomy.
In testing the hypothesis that antibiotic treatment was non-inferior to appendectomy, the researchers assumed that there would be sufficient benefits from avoiding surgery and that a 24% failure rate in the antibiotic group would be acceptable.
Only one of the 273 patients randomized to the surgical group did not undergo successful appendectomy, for an overall success rate of 99.6%.
After one-year follow-up on the 256 patients who received antibiotics instead, 72.7% did not require appendectomy. The remainder underwent surgical intervention within a year of initial presentation for appendicitis, with no intra-abdominal abscesses or other major complications associated with delayed appendectomy.
The intention-to-treat analysis yielded a difference in treatment efficacy between groups of negative 27%. Because of the pre-specified non-inferiority margin of 24%, the researchers were unable to demonstrate non-inferiority of antibiotic treatment relative to surgery in this specific study.
Despite that, the authors write that the majority of patients with uncomplicated acute appendicitis “were successfully treated with antibiotics. These results suggest that patients with CT-proven uncomplicated acute appendicitis should be able to make an informed decision between antibiotic treatment and appendectomy.”
The authors call for future studies focusing both on early identification of complicated acute appendicitis patients needing surgery and to prospectively evaluate the optimal use of antibiotic treatment in patients with uncomplicated acute appendicitis.
In an accompanying commentary, Edward Livingston, MD, deputy editor of JAMA in Chicago, and Corrine Vons, MD, PhD, of the Jean Verdier hospital in Bondy, France, suggest that “the time has come to consider abandoning routine appendectomy for patients with uncomplicated appendicitis. The operation served patients well for more than 100 years. With development of more precise diagnostic capabilities like CT and effective broad-spectrum antibiotics, appendectomy may be unnecessary for uncomplicated appendicitis, which now occurs in the majority of acute appendicitis cases.
“These findings suggest that for CT-diagnosed uncomplicated appendicitis, an initial trial of antibiotics is reasonable followed by elective appendectomy for patients who do not improve with antibiotics or present with recurrent appendicitis,” they add.