This is a big deal… the largest RCT comparing antibiotics vs. surgery for appendicitis and has closed the lid on this research question.
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.
group got IV for 24 hours followed by oral tablets for 10 days.
outcome was an overall health questionnaire at 30 days. Secondary
outcomes were rate of appendicectomy in the antibiotic arm, complications,
return to work etc.
decision to perform appendicectomy in the antibiotic arm was up to the treating
enrolled from May 2016 to February 2020.
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!
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.
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
habits die hard. But kneejerk surgery for appendicitis is now a stinking
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]