Monday 2 November 2020

An RCT comparing antibiotics vs. surgery for appendicitis- the CODA trial

This is a big deal… the largest RCT comparing antibiotics vs. surgery for appendicitis and has closed the lid on this research question.

This non-blinded, pragmatic trial included adults with mostly image proven appendicitis in 25 centers in the USA. They excluded sick patients with shock, diffuse peritonitis, severe phlegmon, free air (microperforations were ok), neoplasm a few other things.

The antibiotic group got IV for 24 hours followed by oral tablets for 10 days.

The primary outcome was an overall health questionnaire at 30 days. Secondary outcomes were rate of appendicectomy in the antibiotic arm, complications, return to work etc.

The decision to perform appendicectomy in the antibiotic arm was up to the treating clinician.


1552 patients were enrolled from May 2016 to February 2020.

Antibiotics were non-inferior to appendectomy based on the 30-day health status. In the antibiotic group, 29% underwent appendicectomy by 90 days. (Those with appendicoliths were more likely to eventually get surgery). Half of the patients randomized to antibiotics were discharged from the Emergency Department!

I would imagine that the rate of appendicectomy could have been lower in this study given it was unblinded… the surgeons struggling to put their scalpels down after decades of surgical dogma.

Of course, this is not the first RCT’s looking at antibiotics for appendicitis. The message is consistent and it is clear where we stand. Antibiotics successfully treat acute uncomplicated appendicitis, but a small percentage (30-40%) of patients eventually get their appendix out.

It is now evident that we need to present patients with treatment options for appendicitis in a shared decision-making process

Yes, old habits die hard. But kneejerk surgery for appendicitis is now a stinking corpse.



Flum DR, Davidson GH, Monsell Se, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Oct 5. doi: 10.1056/NEJMoa2014320. Epub ahead of print. PMID: 33017106. [link to article]

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