Antibiotics a viable treatment for appendicitis: Study

Evelyn Lewin

8/10/2020 2:26:19 PM

The study found most patients who were treated with antibiotics did not require surgery.

Graphic showing appendix in someones adbomen
The research is the largest of its kind conducted to date.

Seven in 10 patients who received antibiotics for appendicitis avoided surgery.
Furthermore, patients who took antibiotics for symptom relief fared no worse in the short-term than those who did undergo surgery.
These are the findings of the Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) study. Published on 6 October in the New England Journal of Medicine, it was the largest study to date comparing the treatment options of surgery versus antibiotics in adults with appendicitis.
It examined 1552 patients between May 2016 and February 2020.
In the study, 776 patients were randomly assigned to receive a 10-day course of antibiotics (based on guidelines from the Surgical Infection Society and Infectious Diseases Society of America), and 776 to undergo an appendicectomy.
Patients in both groups experienced symptoms of appendicitis for roughly the same amount of time prior to treatment.
While patients treated with antibiotics missed less time from work or school than those who had surgery, they also reported more visits to the emergency department and more days spent in hospital overall than those in the surgery group.
David Proud, a colorectal and general surgeon at the Austin Hospital, told newsGP this study offers important insights into treating appendicitis. He says this topic has been studied ‘quite a bit lately’, with surgeons and clinicians interested in the idea of treating appendicitis non-operatively.
‘The big headline is obviously that seven out of 10 people with appendicitis who were treated with antibiotics didn’t need to go to surgery,’ Mr Proud said.
‘But if you look at it the other way, three out of 10 people who were treated with antibiotics did need an operation within three months.’
Either way, the new information adds further insights that can be used to discuss treatment options with patients.

‘The old days of just saying, “You’ve got appendicitis, you need to have your appendix out,” are probably gone,’ says colorectal surgeon David Proud.
‘It means you can have that conversation with someone and say, “You can choose not to have an operation but there’s an approximately one in four chance that you’ll probably end up having an operation in the next little while”,’ Mr Proud said.
‘For some people that might be fine, but other people might elect to have the operation regardless.’
A particularly interesting finding, Mr Proud says, related to patients who were found to have an appendicolith on imaging, as that affected their likelihood of needing surgery after antibiotics.
‘I think a lot of surgeons would recognise that an appendicolith – which is like a little stone in the appendix and is often a cause of appendicitis – is probably a risk factor for more complicated appendicitis,’ he said.
Indeed, the researchers found that four in 10 patients with an appendicolith who received antibiotics required surgery within 90 days of receiving antibiotics as their first treatment.
‘And they had a higher rate of complications than the patients who just went straight to surgery,’ Mr Proud said.
He therefore believes the identification of an appendicolith should play a significant role in potential treatment plans.
‘I would personally recommend that the patient have an operation rather than having just antibiotic treatment, and I think that was borne out by the study,’ he said.
‘Those are the patients that probably should be pushed more towards surgery than a conservative course.’
The researchers note the findings of this study may have been influenced by the fact some of the data was collected during the COVID-19 pandemic. However, they say the conclusions are reassuring for those seeking non-surgical treatment options.
‘We recognise some patients may not want to come into a hospital environment during a pandemic,’ study co-investigator Dr JH Patton said.
‘This study tells us that antibiotics are a viable option for some of these patients.’
Mr Proud says another interesting aspect of the study was that most of the patients received imaging prior to treatment, either a CT scan or an ultrasound.
‘My personal feeling is if you are going to treat someone conservatively then probably they should have a CT scan beforehand,’ he said.
He believes the quality of ultrasound in Australia is ‘probably not ideal’, particularly in adults, so a CT scan is preferred. 
‘You can then exclude an appendicolith and that allows you to risk-stratify people a bit more in terms of which pathway they should go,’ Mr Proud said.
‘I think CT scans are a very useful investigation and that might be one that GPs might think about doing if they don’t want to send someone straight to the emergency department.’
While this research added further evidence to the use of antibiotics, co-investigator Dr Jeffrey Johnson says it also shows ‘there is no one-size-fits-all approach’ in treating appendicitis.
‘Patients ought to evaluate the benefits and risks of taking antibiotics or opting for surgery and make an informed decision on what is important to them,’ he said.
Mr Proud echoes that sentiment.
‘The important thing that comes out of these studies is that they give us more information to be able to have detailed discussions with patients about their treatment options … and potential risks,’ he said.
‘It’s about shared decision-making. The old days of just saying, “You’ve got appendicitis, you need to have your appendix out,” are probably gone.’
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