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Antibiotics effective treatment in lieu of appendectomy
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The majority of patients with uncomplicated acute appendicitis who were treated with antibiotics did not require appendectomy, according to research published in JAMA.
“Appendectomy has been the standard treatment for acute appendicitis for over a century. Although appendectomy is generally well-tolerated, it is a major surgical intervention and can be associated with postoperative morbidity,” Paulina Salminen, MD, PhD, chief of acute and digestive surgery, Turku University Hospital, Finland, and colleagues wrote. “To overcome the limitations of previous trials, we tested the hypothesis that appendicitis can be successfully treated with antibiotics by conducting a multicenter, open-label, noninferiority [randomized controlled trial (RCT)] comparing antibiotic therapy with emergency appendectomy for treating uncomplicated acute appendicitis.”
The Appendicitis Acuta trial included 530 patients aged 18 to 60 years at six Finnish hospitals from November 2009 to June 2012, 273 of whom were scheduled for appendectomy, and 257 of whom received antibiotics. Baseline characteristics were similar between groups.
Of the patients in the surgical group, 99.6% (95% CI, 98%-100%) underwent successful appendectomy, according to Salminen and colleagues. Fifteen patients underwent a laparoscopic appendectomy, and four patients who underwent surgery were found to have complicated appendicitis. Of the patients in the antibiotic group, 72.7% (95% CI, 66.8%-78%) did not require an appendectomy within 1 year of follow-up. Of those who underwent appendectomy, 82.9% (95% CI, 72%-90.8%) had uncomplicated acute appendicitis, 10% (95% CI, 4.1%-19.5%) had complicated acute appendicitis, and 7.1% (95% CI, 2.4%-15.9%) were determined to be susceptible to recurrence.
The researchers also found that the overall complication rate was significantly lower for the antibiotic group (2.8%; 95% CI, 1%-6%) than for the surgical group (20.5%; 95% CI, 15.3%-26.4%).
“Antibiotic treatment of patients with uncomplicated acute appendicitis was not shown to be noninferior to appendectomy for uncomplicated appendicitis within the first year of observation following initial presentation of appendicitis. Nevertheless, the majority (73%) of patients with uncomplicated acute appendicitis were successfully treated with antibiotics,” the researchers wrote. “These results suggest that patients with [computed tomography (CT)]-proven uncomplicated acute appendicitis should be able to make an informed decision between antibiotic treatment and appendectomy. Future studies should focus 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 a related commentary, Edward H. Livingston, MD, deputy editor of JAMA, and Corrine Vons, MD, PhD, division of digestive surgery, Jean-Verdier Hospital, Bondy, France, wrote that the research by Salminen and colleagues did not face the same limitations as previous studies because of its large sample size and the use of CT to confirm uncomplicated appendicitis diagnoses.
“Of those who did undergo surgery, none had major complications attributable to receiving antibiotics before surgery — dispelling the notion that appendectomy is necessarily an emergency,” they wrote. “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 recurring appendicitis.” – by David Jwanier
Disclosure: Salminen reports receiving personal fees for lectures from Merck and Roche. No other relevant financial disclosures were reported.
Perspective
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Thomas M. File Jr., MD
The study by Salminen and colleagues adds to the level of evidence suggesting that a subset of patients with uncomplicated acute appendicitis can be safely and successfully treated with antimicrobial therapy without surgical intervention. Although their study did not meet the pre-study endpoint for 24% noninferiority margin, they did observe that 73% of such patients could be treated in such a manner. Other studies have shown similar results, and a recent meta-analysis concluded: “Antibiotics are both effective and safe as primary treatment by patients with uncomplicated acute appendicitis,” (Varadhan KK, et al. BMJ. 2012;344:e2156).
The most recent Intra-abdominal Infection IDSA guidelines includes a recommendation that nonoperative management of selected patients with acute, nonperforated appendicitis can be considered if there is a marked improvement in the patient’s condition prior to operation (B-II) (Solomkin JS, et al. Clin Infect Dis. 2011;50:133-164). In the Salminen et al study, patients were eligible if there was no evidence of appendicoliths, perforation, abscess or tumor on the basis of a CT scan. The nonoperative patients remained hospitalized for 3 days and received 10 days of “broad spectrum” antimicrobial therapy; the length of hospital stay and duration of antimicrobials were longer than for the appendectomy group, who received only prophylactic antimicrobial doses prior to the incision.
The economic assessment of a longer length of stay vs. the operative cost and the concern for potential adverse effects of the longer use of antimicrobials (including emergence of resistance or C. difficile infection) needs to be further assessed. Future studies should address the possibility of shorter observation within the health care setting, followed by outpatient therapy and consideration of a reduced time of antimicrobials.
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