New analysis has found that outpatient management of appendicitis with antibiotics is safe for some patients, which may allow people to avoid hospitalization and surgery.
Historically, appendicitis treatment has always been surgery — but there is growing evidence that it is safe to treat with antibiotics alone for some patients, even in the comfort of their own home. The researchers found that taking antibiotics on an outpatient basis was not associated with more complications or subsequent appendectomies. The findings were published in Open JAMA Network earlier this month by researchers at Ronald Reagan UCLA Medical Center.
This could have important implications for the treatment of appendicitis and give patients more options, experts told TODAY.
The study was a secondary analysis of Comparison of Antibiotics and Appendectomy Trial (CODA) resultsthe largest randomized controlled trial comparing antibiotic treatment and appendectomy, Dr. David Talan, professor of emergency medicine at the University of California, Los Angeles and lead author of the study, said today.
Appendicitis refers to inflammation of the appendix, which sticks out of the colon in the lower right abdomen and is about the size of a little finger, Talan said. “We believe it is inflamed due to an infection,” which can be caused by bacteria, viruses or parasites, he continued. Untreated appendicitis can cause the appendix to rupture, which can be life-threatening. Treatment is usually surgery to remove the appendix, or appendectomy, Talan said. There are 250,000 cases of appendicitis in the United States every year.
In the early 1900s, with the advent of anesthesia, it was common to remove the appendix at the first sign of appendicitis and to give antibiotics after surgery to decrease the risk of postoperative infections, “but no one thought hey, let’s try antibiotics from surgery instead,” until decades later, Talan said.
Today, imaging like CT scans allow doctors to accurately diagnose appendicitis, as well as its stage, Talan said. Most people have early-stage appendicitis, also called localized or uncomplicated appendicitis, he added.
“People started doing clinical trials comparing just giving antibiotics to routine and emergency appendectomy,” Talan said. The largest of these, the CODA trial, compared a 10-day course of antibiotics with appendectomy in patients at 25 US hospitals. From May 2016 to February 2020, 1,552 adults with acute appendicitis were randomized to receive either antibiotics or appendectomy. The study found that antibiotics were not inferior to appendectomy in some patients, said Talan, co-principal investigator of the CODA trial.
This new study looked at the safety of outpatient management among patients in the CODA trial who were assigned to get antibiotics, Talan said.
“As long as the patients were responsible, if the doctors felt that they were stable, their pain was under control, their condition had not worsened… the doctors were allowed to send these people home on oral antibiotics for that they are treated outside of the hospital,” explained Talan.
The researchers examined the incidence of serious adverse events, such as death, life-threatening events, treatment-related disability and unrelated hospitalization, in these patients, and also compared health outcomes, care visits emergency and subsequent appendectomies, as appendicitis may recur after treatment. with antibiotics, says Talan.
The study found that of the 726 participants who received antibiotics, 46% who met stability criteria were discharged within 24 hours, and outpatient care was associated with less than 1 serious adverse event per 100 participants during the first seven days after discharge.
People who received antibiotics on an outpatient basis did not have a higher incidence of appendectomies in the first week or at 30 days compared to those who were hospitalized. “Less than 5% of participants treated as outpatients returned for unplanned outpatient care,” the study authors wrote.
“We found it to be safe…because the rates (of serious adverse events) were not higher. In fact, there was a tendency for (serious adverse events) and subsequent appendectomies to be fewer among those who felt stable to go home,” Talan said. The study authors concluded that most patients who choose antibiotics can avoid hospitalization and complete treatment at home “without incurring an increased risk of serious complications or appendectomy.”
Appendectomies are still common even though antibiotics are a safe first-line alternative, Talan said, but at least for now, patients with uncomplicated appendicitis have more options. “For 120 years, we have put people in the hospital and taken them to surgery. And now it looks like people can avoid surgery, and even be at home and overcome this condition,” Talan said.
As the study authors wrote, this option should be included when healthcare providers guide patients with appendicitis through their treatment options. “We have two approaches that are safe, but they have different advantages and disadvantages. … The best approach for you is the one whose results you enjoy the most,” Talan said.
Avoiding surgery and hospitalization can be an attractive and cost-effective option for many people. According to the study authors, outpatient antibiotic treatment could help patients miss less work and reduce appendicitis-related healthcare costs.
“These trials don’t tell us that there is a better way to treat appendicitis. … They tell us you have options, and each option has its own risks,” Dr. F. Perry Wilson, an associate professor at Yale School of Medicine who was not involved in the study, said today.
Appendicitis used to be a uniform surgical diagnosis, but “what has been found is that a significant number of these cases, perhaps even the majority, can be treated with antibiotics,” Wilson said. .
That said, it’s not the cure for all situations, and sometimes surgery is the only option, as antibiotics won’t prevent appendicitis from recurring. “For many of these people, even if the appendicitis improves, they might have recurring appendicitis that will require surgery,” Wilson said.
It is important to note that all study participants had uncomplicated appendicitis. “There was a screening process to make sure they weren’t too sick to get antibiotics…so it wouldn’t apply to people with sepsis for example,” he said.
“We’re still going to see a lot of appendicitis surgery. This (study) doesn’t remove that just yet, but it certainly gives people some respite…and one more treatment option if you’re willing to accept the risk and responsibility. »