This article is more than 5 years old. Information may no longer be current.
Antibiotics inferior to surgery for uncomplicated appendicitis, but experts deem ‘safe first-line therapy’
Click Here to Manage Email Alerts
Antibiotic treatment did not meet criteria for noninferiority compared with appendectomy for patients with uncomplicated appendicitis, although most who received antibiotics did not require surgery or have significant complications if they did, according to new research data.
Aiming to compare antibiotic therapy with emergency appendectomy for uncomplicated acute appendicitis, Paulina Salminen, MD, PhD, from Turku University Hospital in Finland, and colleagues performed the open-label, noninferiority, randomized Appendicitis Acuta (APPAC) trial at six Finnish hospitals from November 2009 to June 2012.
Paulina Salminen
“The study hypothesis was that the majority of patients with uncomplicated acute appendicitis can be treated without surgery by using effective antibiotic therapy, thus avoiding a large number of unnecessary appendectomies,” Salminen told Healio.com/Gastroenterology.
They recruited 530 patients aged 18 to 60 years with CT-confirmed uncomplicated acute appendicitis who were randomly assigned to undergo early appendectomy (n = 273) or receive antibiotic treatment (n = 257; 1 g per day intravenous ertapenem [Invanz, Merck Sharp Dohme] for 3 days followed by 500 mg oral levofloxacin once daily and 500 mg metronidazole 3 times per day for 7 days) and were then followed for 1 year. The primary endpoint for surgery was successful appendectomy and the primary endpoint for antibiotics was hospital discharge without need for surgery or recurrent appendicitis during follow-up. Based on prior studies, the researchers anticipated a 24% difference in treatment efficacy between groups.
The surgical success rate in the appendectomy group was 99.6% (95% CI, 98%-100%). In the antibiotic group, 27.3% (95% CI, 22%-33.2%) had an appendectomy within a year of initial presentation and 72.7% (95% CI, 66.8%-78%) did not require surgery. Intention-to-treat analysis showed a – 27% difference in treatment efficacy between groups, which did not satisfy the prespecified noninferiority margin of 24%.
‘Safe first-line therapy’
The majority of “patients initially treated with antibiotic therapy did not require surgery during the 1-year follow-up period,” Salminen said. “Of those who did undergo surgery, none had major complications attributable to a delayed appendectomy or receiving antibiotics before surgery. This suggests that not only is CT scan-confirmed uncomplicated acute appendicitis not a surgical emergency, but that possible delay in surgical treatment when preceded by a course of antibiotics has few consequences and antibiotic therapy for uncomplicated acute appendicitis is a safe first-line therapy.”
“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,” Edward Livingston, MD, deputy editor of JAMA, and Corrine Vons, MD, PhD, from the Jean Verdier Hospital in France, wrote in an accompanying editorial. “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.”
“Future studies should focus both on prospectively evaluating the optimal use of antibiotic treatment in patients with uncomplicated acute appendicitis and in early identification of complicated acute appendicitis patients needing surgery,” Salminen said. “There are promising results of low-dose CT scans for diagnosing acute appendicitis and low-dose CT scan should be further evaluated in diagnosing appendicitis, as a precise CT diagnosis enables the evaluation of the optimal treatment for acute appendicitis patients.” – by Adam Leitenberger
Disclosures: Salminen reports she received personal fees for lectures from Merck and Roche. Livingston and Vons report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Click Here to Manage Email Alerts