Friday 28 August 2015

Antibiotic Therapy for Appendicitis- Time for a Paradigm shift?

The answer is yes... probably

Surgical treatment of appendicitis has traditionally been as linked as fish and chips (or perhaps burgers and fries). But it looks like the steadfast notion is finally being demolished.

There have been a bunch of studies over the past decade looking at the success of antibiotic therapy alone for the treatment of appendicitis. These small studies with mixed research methods have pretty much all said the same thing. Most of the time you can get away with antibiotics but a small proportion of patients will eventually get their appendix out anyway over the ensuing few months due to recurrence.

Now along comes the largest randomized trial trying to definitively answer the question. This was a non-inferiority RCT out of Finland that enrolled patients aged 18-60 with CT proven uncomplicated appendicitis. Patients were randomized to antibiotics alone vs. traditional appendectomy. The antibiotic group got three days of IV ertapenem (a big gun carbapenem) followed by a week of oral levofloxacin and metronidazole. Shortly afterward these patients had C diff diarrhea and disulfuram reactions... why would I make this up?

The primary outcome of importance was success of antibiotic treatment without having to get an appendectomy during a one year follow up period. They chose a fairly arbitrary non-inferiority margin of 24% but the authors seem to appropriately dismiss this in the end anyway.

As expected, the surgical group did pretty well. They had the expected minor complications and these Finnish patients were back to work in a median of 19 days. None of their appendixes grew back.

The antibiotic group also faired pretty well and were back to work in 7 days. But by the end of the one year follow up, 27% ended getting their appendixes out anyway.

One could interpret the outcomes in a couple of ways. Is 73% success by one year good enough? What do you think? Or probably more importantly, what do our patients think?

Regardless of what health care professionals believe, I believe it is time for patients to become involved in shared decision making. The data is now fairly robust and can’t be ignored any longer. It is time for us to consider non-surgical treatment for uncomplicated appendicitis as a valid treatment option and offer this to our patients.  

(As an aside, we probably don’t need to resort to such crazy heavy hitting antibiotics. Some studies have just used oral Augmentin. But in the end, this will be a judgement call and extrapolating from existing literature.)

Old habits die hard. This is especially true for surgeons who love their knives. After all, “cold steel heals.” But perhaps the push needs to come before the surgeons get involved. Is 73% good enough? Let’s ask our patients before we call man with knife.

Salminen P, Paajanen H, Rautio T, et al. Antiobiotic Therapy vs. Appendectomy for Treatment of Uncomplicated Acute Appendicitis. The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340-2348.

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