NEJM: CODA RCT | Pills or Knife for Appendicitis – Long-Term Outcomes

Written by Rebecca Breed

Spoon Feed
The CODA trial initially found antibiotic treatment was noninferior to surgery for acute appendicitis at 30 days. In this follow up letter on long-term outcomes (up to 4 years), the incidence of appendectomy in the antibiotic group was higher than pooled results from prior trials.

Why does this matter?
The Comparison of Outcomes of Antibiotic Drugs and Appendectomy trial (CODA) trial showed promise for antibiotics compared to appendectomy for short-term outcomes in patients with appendicitis. How did these patients do down the road?

Pills vs The Knife
Follow-up data showed 40% of patients who were initially treated in the antibiotic group had subsequent appendectomy at year 1; 46% at year 2; 49% at years 3 and 4. Appendectomy was more common among patients who had an appendicolith initially, though this greater risk seemed to dissipate over time. Authors also noted that by 2 years, 14% of patients in the antibiotic group required another course of antibiotics and subsequently 66% of those patients underwent appendectomy. This follow-up data is limited by the fact that many patients were lost to follow-up and authors were only able to collect data for 57% at year 2, 10% at year 3 and 5% at year 4.  Although this update on long-term outcomes isn’t that encouraging, antibiotic treatment remains an option, and this provides us additional data to discuss with our patients when utilizing shared decision-making regarding treatment for appendicitis.

Source
Antibiotics versus Appendectomy for Acute Appendicitis – Longer-Term Outcomes. N Engl J Med. 2021 Dec 16;385(25):2395-2397. doi: 10.1056/NEJMc2116018. Epub 2021 Oct 25.

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