Antibiotics safe for some outpatients with acute appendicitis

Some patients with acute appendicitis who were discharged from hospital within 24 hours were safely managed with antibiotics on an outpatient basis, according to a secondary analysis from the CODA Collaborative trial.

Among more than 700 patients, serious adverse events occurred in 0.9 per 100 outpatients versus 1.3 per 100 inpatients for 7 days, reported David Talan, MD, of Ronald Reagan UCLA Medical Center in Los Angeles, and these partner’work.

Within 30 days, serious adverse events occurred in 1.8 per 100 outpatients and 3.1 per 100 inpatients, the authors noted in Open JAMA Network.

Additionally, significantly fewer outpatients treated with antibiotics required appendectomy at 30 days compared to hospitalized patients (12.6% versus 19.0%).

Outpatients also missed fewer days of work per week (2.6 versus 3.8 days) and reported similar satisfaction with their chosen treatment compared to the inpatient group, with a similar frequency of return medical visits at 7 days and equally high quality of life scores at 30 days. (mean EuroQol 5-dimensional score 0.93 versus 0.92, respectively).

“Most patients with appendicitis can be treated with antibiotics instead of surgery, and most who choose this type of care can be treated safely on an outpatient basis, usually avoiding hospitalization and surgery” , Talan said. MedPage today. “Outpatient management has been shown to be safe in up to 90% of patients with appendicitis.”

“In today’s complex medical environment, the focus must always be on optimal clinical outcomes and delivering the highest value health care,” said Diya Alaedeen, MD, of the Cleveland Clinic. in Ohio. “This sub-study of the CODA trial, although it has its own limitations, may pave the way for a new paradigm shift in the treatment of highly selected patients with appendicitis on an outpatient basis, thereby changing the narrative about the appendicitis from that of an emergent surgical disease to that of treating and releasing.”

The open-label CODA trial showed that antibiotics were not inferior to appendectomy, Talan’s group noted. In 2020, the American College of Surgeons released guidelines that recommended that most patients with uncomplicated appendicitis be treated with antibiotics rather than an appendectomy during the COVID-19 pandemic.

However, follow-up data from CODA showed that patients often required appendectomy after antibiotics. Additionally, the presence of an appendicolith may increase the risk of surgery within 30 days of starting antibiotics.

For this secondary analysis, Talan and colleagues reviewed data from 726 patients with imaging-confirmed appendicitis at 25 US hospitals from May 2016 to February 2020. The median patient age was 36 years, 63.6% were of men and 60.2% were white.

Of the 726 patients, 335 were discharged within 24 hours and 391 were discharged after 24 hours.

Analyzes were adjusted for age, fever, Charlson comorbidity index, Alvarado score, nausea/vomiting, pain score and appendicolitis on imaging, among other factors, but did not take into account unmeasured differences, such as changes in clinical symptoms.

In the appendicolith subgroup, serious adverse events occurred in 2.3 per 100 outpatients versus 2.8 per 100 inpatients for 7 days.

No deaths were reported in either group.

Talan and his team acknowledged that unaccounted factors may have differentiated patients discharged early from the hospitalized group. Also, because this was not a randomized trial in which patients were assigned to early discharge or hospital care, they did not directly assess comparative effectiveness, they said.