BACKGROUND AND PURPOSE:

• Appendectomy has been the standard of care for appendicitis
• Modern imaging techniques (CT) allows for the determination of complicated vs uncomplicated appendicitis
• Prior RCT with 1 year follow-up demonstrated that 73% of patients could avoid surgery and be treated with antibiotics alone
• Salminen et al. (JAMA, 2018) assessed long-term outcomes in patients enrolled in the above study at 5 years

METHODS:

• Five-year observational follow-up of patients in the Appendicitis Acuta (APPAC) multicenter RCT (open-label)
• Participants
  • 18 to 60 years
  • CT-confirmed uncomplicated acute appendicitis
• Patients had either received either
  • Open appendectomy
  • Antibiotic therapy: IV ertapenem (1 g/d) for 3 days, then 7 days of oral levofloxacin (500 mg daily) and metronidazole (500 mg 3 times/day)
• Follow-up
  • Phone interview between 3 to 5 years after intervention
  • Record search if unavailable for interview
• Outcomes
  • Late appendicitis recurrence (>1 year) after antibiotic treatment | Complications (surgical site infections, incisional hernias, abdominal pain, and obstructive symptoms) | Length of hospital stay | Sick leave

RESULTS:

• 530 patients were randomized
  • 273 patients underwent appendectomy | 257 received antibiotics
• 70 (27.3%) patients in the antibiotics group underwent appendectomy within the first year
• 30 (16.1%) additional antibiotic-treated patients underwent appendectomy between 1 and 5 years
• The cumulative incidence of appendicitis recurrence was
  • 34.0% at 2 years
  • 35.2% at 3 years
  • 37.1% at 4 years
  • 39.1% at 5 years
• Of the 85 patients in the antibiotic group who subsequently underwent appendectomy for recurrent appendicitis
  • 76 had uncomplicated appendicitis
  • 2 had complicated appendicitis
  • 7 did not have appendicitis.
• At 5 years, the overall complication rate was higher in the appendectomy group (P < .001)
  • Appendectomy group: 24.4%
  • Antibiotics group: 6.5%
• There was no difference between groups for
  • Length of hospital stay
• There was a significant difference in sick leave in the appendectomy group (P < .001)
  • Appendectomy group: 22 days
  • Antibiotics group: 11 days

CONCLUSION:

• The recurrence rate for appendicitis following antibiotic treatment at 5 years was 39.1%, supporting feasibility of antibiotic treatment
• Complication rate was 17.9 percentage points higher than after surgery compared to antibiotics

Learn More – Primary Sources:

Five-Year Follow-up of Antibiotic Therapy for Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial

Related ObG Topics:

Ongoing Pelvic / Lower Abdominal Pain and a Negative Work-Up: What Next?

The ABCs of PID Diagnosis – What You Need to Know

Pelvic Inflammatory Disease – CDC Treatment Guidelines