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#Grand Rounds

Antibiotic Treatment Instead of Appendectomy for Uncomplicated Appendicitis – Long-Term Outcomes at 5 Years

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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

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