Outpatient antibiotic management safe for select adults with acute appendicitis
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Outpatient antibiotic management was safe compared with in-hospital care, with no greater risk for complications or appendectomy, in a subgroup of patients with acute appendicitis, according to research.
“The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial was the largest reported randomized clinical trial comparing antibiotic treatment and appendectomy for patients with imaging-confirmed appendicitis. The CODA trial found antibiotics to be noninferior to appendectomy for a 30-day general health measure, the EuroQol 5-dimension (EQ-5D) score,” David A. Talan, MD, of the department of emergency medicine at Ronald Reagan UCLA Medical Center, and colleagues wrote in JAMA Network Open. “In 2020, after publication of initial CODA trial results, the American College of Surgeons issued guidelines stating that high-quality evidence indicates that most patients can be treated with antibiotics rather than appendectomy. Outpatient management, if safe and effective, potentially affords greater patient convenience and reduced health care use and costs.”
In a secondary analysis cohort study, Talan and colleagues investigated the use and safety of outpatient management among 776 patients with appendicitis who received antibiotics at 25 U.S. hospitals from May 2016 to February 2020. Researchers defined outpatient management and hospitalization as discharge within or after 24 hours, respectively.
Among participants randomized to receive antibiotics, 5.4% underwent appendectomy within 24 hours and 1% did not receive their first antibiotic dosage within 24 hours. Of the remaining 726 patients (median age, 36 years; 63.6% men; 60.2% white), 46.1% were discharged within 24 hours, while 53.9% were discharged after 24 hours.
Serious adverse events were reported over 7 days in 0.9 (95% CI, 0.2-2.6) per 100 participants discharged within 24 hours and 1.3 (95% CI, 0.4-2.9) per 100 participants discharged after 24 hours. In a subgroup of patients with appendicolith, serious adverse events occurred among 2.3 (95% CI, 0.3-8.2) and 2.8 (95% CI, 0.6-7.9) per 100 participants, respectively.
Further analysis showed incidence of appendectomy at 7 days among 9.9% of outpatients (95% CI, 6.9-13.7) and 14.1% of inpatients (95% CI, 10.8-18). At 30 days, 12.6% (95% CI, 9.1-16.7) and 19% (95% CI, 15.1-23.4), respectively, underwent appendectomy.
Overall, both patient groups reported low rates of treatment dissatisfaction and similarly high EQ-5D scores at 30 days, with National Surgical Quality Improvement Program events occurring in 1.8 (95% CI, 0.8-3.9) per 100 outpatients and 5.6 (95% CI, 3.5-8.5) per 100 hospitalized patients. Outpatients also missed fewer workdays (2.6 days; 95% CI, 2.3-2.9) compared with patients who were hospitalized (3.8 days; 95% CI, 3.4-4.3).
“The findings of this cohort study support that outpatient antibiotic management is safe for selected adults with acute appendicitis. It appears that most patients who choose antibiotics can avoid hospitalization without incurring increased risk of serious complications or appendectomy,” Talan and colleagues concluded. “Outpatient management should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care.”
Perspective
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This secondary analysis of the CODA trial provides a more objective perspective when deciding between operative and nonoperative treatment for those with uncomplicated appendicitis. The 10% and 14% of patients in the nonoperative treatment group who still required an appendectomy after 7 and 30 days, respectively, may point to the benefits of a surgical approach for some patients. For others, safe outpatient antibiotic management may be a more beneficial alternative to surgery.
The “risk worth taking” will vary from patient to patient. These findings should thus be included in the decision-making discussion between the patient and physician.
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