Most patients with uncomplicated acute appendicitis prefer antibiotic therapy over surgery
Click Here to Manage Email Alerts
Adults with uncomplicated acute appendicitis who were treated with antibiotics and did not need surgery at a later date were as satisfied with their treatment experience as those who went through surgery, according to a secondary analysis of a randomized clinical trial that appeared in JAMA Surgery.
Additionally, both groups had comparable quality of life, researchers said.
“To our knowledge, no other study has been conducted on the long-term quality of life and patient satisfaction of adult patients randomized to receive antibiotic therapy or appendectomy for the treatment of uncomplicated acute appendicitis,” Suvi Sippola, MD, of the division of digestive surgery and urology at the University of Turku and Turku University Hospital in Finland, and colleagues wrote.
The researchers analyzed interviews from 423 patients enrolled in the Appendicitis Acuta (APPAC) trial who had been randomly assigned to antibiotic treatment (n = 206) or open appendectomy (n = 217). Patients in the antibiotic arm received 1 g ertapenem intravenously once daily for 3 days, followed by 500 mg oral levofloxacin once daily for 7 days and 500 mg oral metronidazole three times a day for 7 days. Among the patients who received antibiotics, 81 also had an appendectomy. According to the researchers, the median follow-up was 7 years.
Sippola and colleagues found that the quality of life between the antibiotic and appendectomy cohorts was similar (median health index value in both groups = 1; 95% CI, 0.86-1). The cohort that underwent appendectomy was more satisfied with their treatment than the cohort that took antibiotics — but a sub-group analysis showed that the difference was based on patients who took antibiotics but also had to undergo surgery.
In fact, there was no difference in patient satisfaction after successful antibiotic treatment vs. appendectomy (cumulative OR = 7.8; 95% CI, 0.5-1.3). Patients who had an appendectomy or successful antibiotic therapy (cumulative OR = 7.7; 95% CI, 4.6-12.9) were more satisfied than patients who took antibiotics and later underwent appendectomy (cumulative OR = 9.7; 95% CI, 5.4-15.3). Of the 81 patients who took antibiotics and later had an appendectomy, 27 said they would again choose antibiotics as their primary treatment.
Sippola and colleagues wrote that the results underscore “the importance of discovering potential parameters predictive of appendicitis recurrence.”
In a related editorial, Edward Livingston, MD, of the department of surgery at the University of California, Los Angeles, wrote that it would be wrong to pay attention only to the patient satisfaction scores reported by Sippola and colleagues.
“Unlike chronic pain conditions, which have a principal effect on patients of a decrement
in quality of life, appendicitis is an acute infection,” Livingston wrote. “Infections can spread and cause serious disability or even death if not properly managed. The most important outcome when assessing the effectiveness of appendicitis treatment is its ability to avoid infectious complications.”
Previously published analyses from this same trial showed that in the cohort initially treated with antibiotics, the cumulative incidence of appendicitis recurring was 34% at 2 years, 35.2% at 3 years, 37.1% at 4 years and 39.1% at 5 years. Other previously published findings indicated that the surgical success rate in the appendectomy cohort was 99.6% (95% CI, 98-100). In the antibiotic group, 27.3% (95% CI, 22-33.2) had an appendectomy within 1 year of initial presentation and 72.7% (95% CI, 66.8-78) did not need surgery. In his editorial, Livingston wrote that these and other “numerous” outcomes reported in the APPAC trial should guide treatment decisions. – by Janel Miller
Disclosures: Livingston reports no relevant financial disclosures. Sippola reports receiving grants from Mary and Georg C. Ehrnrooth Foundation and Turku University Hospital during the conduct of the study. Please see the study for all other authors’ relevant financial disclosures.
Perspective
Back to Top
John M. Porter, MD
The study was well done, but a limitation of it is that most appendectomies in the United States are done laparoscopically, not open. That could change patient satisfaction in the appendectomy group. This study will improve the decision-making between the patient and surgeon and allow the surgeon to add information about long-term follow-up to the informed consent process with the patient, thus allowing the patient to make a more informed decision on the treatment options of antibiotics and appendectomy. More information for the patient is always a positive. And though liberal use of antibiotics always increases the risk for increasing resistance, that risk is worth taking if there is benefit to the patient. This study is one example where the benefit outweighs the risk.
Read more about
Click Here to Manage Email Alerts