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January 15, 2024 FROM NEJM
Written by Seth Walsh-Blackmore
This expert opinion piece recommends consideration of nonoperative antibiotic treatment for select cases of uncomplicated acute appendicitis.
Who is happy keeping an appy?
Acute appendicitis is a widespread and actionable pathology seen by EPs in all practice settings. The majority of these cases will be uncomplicated when identified early. Uncomplicated means no perforation, large abscess/phlegmon, or additional concerning findings on imaging.
The CODA, APPAC, and MWSPC (pediatric) trials suggest select patients presenting with uncomplicated appendicitis will have similar clinical improvement and short-term quality of life outcomes (ex. EQ-5D) with antibiotics alone vs urgent appendectomy.
These select patients are hemodynamically stable, not septic, pregnant, immunocompromised, or with a history of inflammatory bowel disease. Antibiotic therapy means at least 24 hours of IV therapy directed against gram-negative and anaerobes followed by 7-10 days of oral treatment with similar coverage. The authors caution against ampicillin-sulbactam and amoxicillin-clavulanate citing the high rates of E. coli resistance.
The nonoperative patients were more likely to experience a subsequent hospitalization for any cause, and within a year, 25-40% of them ultimately received an appendectomy. Despite this, they experienced significantly fewer days of being unable to work or participate in everyday activities. Nonoperative management did not increase major long-term complications, and no deaths occurred in either group.
The authors conclude that nonoperative management is safe and reasonable in select patients, emphasizing the importance of shared decision-making. This agrees with the recommendations of several surgical professional societies (ACS, AAST, WSES, NIHCE).
Caveats include that only the CODA trial included patients with appendicolith. These patients experienced higher rates of early treatment failure and some complications with nonoperative management. There is a small (0.9%) incidence of cancer detection with appendectomy, which is more significant in older patients. Older (>45y) patients may also not respond as well to initial antibiotics.
How will this change my practice?
The definitive treatment of appendicitis remains appendectomy. These data suggest uncomplicated appendicitis has treatment flexibility, for example, if a personal issue complicates immediate surgery. Shared decision-making and reliable follow-up are critical, as is discussion with the surgical team. Remember that operative cases also get immediate antibiotics!
Another Spoonful
How fast should an appendectomy get to the OR? A recent RCT asked that question.
Source
Treatment of Acute Uncomplicated Appendicitis. Treatment of Acute Uncomplicated Appendicitis. N Engl J Med. 2021 Sep 16;385(12):1116-1123. doi: 10.1056/NEJMcp2107675.
