Appendicitis: Longer Antibiotic Treatment May Not Help

Lara C. Pullen, PhD

November 27, 2015

Patients with acute complicated appendicitis who received 5 days of postoperative antibiotic treatment after laparoscopic appendectomy surgery did not have a reduction in infectious complications relative to patients receiving only 3 days of postoperative antibiotic treatment, according to the results of a new study.

"Longer administration of antibiotics was not associated with prevention of intra-abdominal abscesses and a reactive strategy based on clinical condition of the patient is therefore advised," the study authors say.

Charles C. van Rossem, MD, from Tergooi Hospital in the Netherlands, and colleagues from the Snapshot Appendicitis Collaborative Study Group published the results of their national, multicenter prospective study online November 18 in JAMA Surgery.

The researchers evaluated 1975 patients from 62 Dutch hospitals. The majority (96.3%) underwent an appendectomy for acute appendicitis, and three quarters of these had laparoscopy. Although the study included patients with acute complicated appendicitis, the investigators note that histological severity did not correlate with clinical severity in clinically assessed complicated cases.

Three days of antibiotics (instead of 5 days) had no significant effect on any infectious complication (odds ratio, 0.93; 95% confidence interval, 0.38 - 2.32; P = .88). Perforation of the appendix was the only identified risk factor associated with infectious complication (odds ratio, 4.90; 95% confidence interval, 1.41 - 17.06; P = .01). The results are consistent with findings from a previously published cohort study and a previously published small, randomized clinical trial.

In the Netherlands, patients with acute appendicitis are primarily treated by laparoscopic surgery. The length of antibiotic prescription is often dictated by clinical evaluation of the patient. The new data suggest that such a modification of length does not affect disease severity or outcome.

Antibiotics vs Surgery

The current study adds to the discussion of how best to treat patients with acute appendicitis and of the role of antibiotics. Earlier this year, JAMA published the results of the Appendicitis Acuta trial, a large, multicenter, randomized clinical trial that relied on computed tomography to confirm the presence of uncomplicated appendicitis and that treated these patients with either antibiotics or appendectomy plus antibiotics. As previously reported by Medscape Medical News, the study results indicated that antibiotic therapy alone may be sufficient for uncomplicated appendicitis.

The findings attracted extensive media coverage and prompted strong responses from surgeons, note Steven J. Hasday, BS, from the University of Michigan Medical School in Ann Arbor, and colleagues in an editorial accompanying the current paper by Dr van Rossem and colleagues.

The data were interpreted by the media to mean that appendicitis can be treated by antibiotics alone. Surgeons, in contrast, were resistant to the idea of forgoing surgery in the treatment of appendicitis.

The ensuing discussion largely focused on the controversy of the results. In many cases, the needs of the patients were sidelined.

"Rather than a surgeon-centric debate about whether antibiotics are 'valid,' the discussion we need to have is about how surgeons can best engage in shared decision making with patients on treatment options for appendicitis," the editorialists write. "Shared medical decision making is the process by which physicians and patients reach a mutually agreeable decision for treatment by considering patient values and preferences along with the specific risks and benefits of treatment options. Through shared decision making we can answer the question that we should be asking: which is the right option for this patient?"

They add that the new data provide yet another opportunity for the surgeon to engage in conversation with their patients.

The authors have disclosed no relevant financial relationships. One editorialist is a cofounder of ArborMetrix Inc, a company that makes software for profiling hospital quality and efficiency.

JAMA Surg. Published online November 18, 2015. Full text, Editorial extract

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