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Antibiotics Can Be as Effective as Surgery in Some Appendicitis Cases

  • A new study points out that antibiotics can be effective in treating appendicitis.
  • The researchers said that in some cases the antibiotics can eliminate the need for surgery.
  • Experts say antibiotics have been used for years to treat some cases of appendicitis, but many physicians still prefer surgery due to the complications that can occur with an infection of the appendix.

What do you do when you have an appendicitis attack?

If your first thought is an appendectomy, you’re in good company. It’s been the standard treatment for a long time.

But it’s not always the only option.

Antibiotics can eliminate or delay the need for appendectomy, at least in some cases, according to research published in the New England Journal of Medicine (NEJM).

It’s not a new treatment. But preliminary outcome results from the largest clinical trial to date on the subject give doctors and their patients more to consider.

What the research says

The Comparison of the Outcomes of antibiotic Drugs and Appendectomy (CODA) trial involved 1,552 appendicitis patients in 25 hospitals across 14 states.

Participants in the nonblinded, noninferiority trial were randomized to have an appendectomy or get a 10-day course of antibiotics first.

Antibiotics were administered intravenously for at least 24 hours before switching to oral medication.

The primary outcome was a 30-day health status. Secondary outcomes included appendectomy for those in the antibiotics group and complications through 90 days.

Of those who had antibiotic treatment, 30 percent ended up having an appendectomy within 90 days. The risk for complications and appendectomy was higher for people with an appendicolith, which is a calcified deposit in the appendix.

Those in the antibiotics group returned to the emergency room more often. But overall time in the hospital was similar between the two groups. People treated with antibiotics missed less time from work or school.

All in all, antibiotic treatment was found to be noninferior to appendectomy.

Additional results of the CODA trial will be shared over the next 2 years.

What the experts say

Dr. Ken Perry is an emergency physician and assistant medical director of the Trident Emergency Department at the Trident Medical Center in Charleston, South Carolina.

Perry told Healthline that appendicitis is a diagnosis he has to make on a daily basis.

“Appendectomy was classically a very common surgery that had very little second-guessing for many years. Studies like this one in the NEJM will allow doctors to give better guidance to patients and help them receive the treatment that best fits their medical condition,” said Perry.

“There are other diagnoses, such as diverticulitis, that have changed the way we think of appendicitis,” he added.

Diverticula are small pouches that form along the digestive tract, which can then become infected.

“Although the appendix is not formed in the same way, as it is its own organ/structure, they can both get infected by similar bacteria and in similar ways. Since clinicians are comfortable with antibiotics for diverticulitis, there is at least precedent to a similar treatment plan,” said Perry.

Dr. John S. Kennedy is a general surgeon at DeKalb Surgical Associates and on staff at Emory Hospital in the Atlanta area. In practice for 33 years, he’s taken care of hundreds of people with appendicitis, treating some with antibiotics and others with surgery.

Kennedy noted that half of the 8,168 appendicitis patients assessed were excluded for various reasons. He also observed that the research did not include children.

“Diagnosis was basically made by what the CT scan showed, so there may have been patients who didn’t even need antibiotics (a CT scan can be false-positive),” Kennedy told Healthline.

“Follow-up was only 90 days. So, the number of patients who ultimately avoided surgery is definitely lower than 70 percent,” he said.

What you need to consider

Appendicitis is an infection or inflammation of your appendix.

Pain may start around the navel, then move to the lower right abdomen. You might also have abdominal tenderness, nausea, and vomiting. If you have symptoms of appendicitis, seek immediate medical attention.

Untreated, appendicitis can lead to serious complications. The appendix can rupture and leak bacteria and pus into the abdominal cavity. This is a potentially life threatening event.

Perry advises people to consider the risks of each treatment plan.

“There is always a risk of appendix rupture if the antibiotics do not adequately treat the infection. Surgery is not without its own risks. This study allows for a better discussion with patients about the risk/benefit profile of either treatment plan,” he continued.

Kennedy suggests that people also give thought to how sick they feel.

“If I were the patient, and wasn’t very tender, and didn’t have fever or vomiting, and didn’t have a high white count, I think I’d skip the surgery,” he said.

“If it’s a complicated appendicitis at diagnosis, you probably need surgery, period. If you are given the option of antibiotics, are you OK with the 30 percent or higher possibility of needing an operation later on?” continued Kennedy.

What doctors need to consider

Taking into account the failure rate of antibiotics when there’s an appendicolith, Kennedy advises appendectomy in these cases.

He noted that surgeons should also consider:

  • other conditions that cause right lower quadrant pain
  • flexibility in scheduling for people who start on antibiotics but then need or want an appendectomy
  • if treating with antibiotics, whether your patient will be compliant with the necessary follow-up

Although antibiotics help some people avoid surgery, it’s not for everyone.

“Some surgeons feel that a 30 percent ‘failure rate’ for antibiotics is way too high and don’t subscribe to even considering it. And some patients worry that the surgeon, whom they’ve just met, might not be offering the best treatment if they don’t get surgery,” said Kennedy.

Perry said that for now, the general practice is still to remove the appendix.

“Even with this study that is pretty convincing that antibiotics are a viable treatment plan, it would be difficult to convince patients and their doctors to adopt antibiotics alone for appendicitis,” said Perry.

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  • Posted on October 12, 2020