Evaluating Antibiotic Therapy as Treatment for Acute Appendicitis
The Article: Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis. P. Salminen et al. JAMA, 2015.
The Idea: Multiple recent RCTs suggest that antibiotic treatment may offer an acceptable alternative to surgery for acute appendicitis in certain patients.
The Study: This study was a multicenter, open-label, prospective, non-inferiority RCT comparing antibiotics to emergency appendectomy for uncomplicated acute appendicitis.
The cutoff for non-inferiority was 24% difference between treatment arms. The power for the primary outcome was 0.86. 273 participants were randomized to appendectomy and 257 to antibiotics. Both groups were followed for one year. The baseline characteristics between treatment groups appear similar. Participants randomized to antibiotics received ertapenem 1g IV daily x3d followed by outpatient levofloxacin/metronidazole x7d.
Primary Outcomes for the antibiotic group were resolution of acute appendicitis with discharge from the hospital without surgery and no recurrent appendicitis in the year after treatment. Primary outcome for the surgery group was a successful appendectomy.
The Findings: The primary outcome for the surgical group was surgery (all except for 1 patient whose symptoms resolved). The primary outcome for the antibiotic group was resolution of appendicitis for one year and no surgery during initial hospitalization. This was achieved in 73% of patients. 15 received surgery during the initial hospitalization (about half had complicated appendicitis, the other half uncomplicated) and 55 were operated on during the year. The difference in efficacy between the two groups was 27% (99.6-72.7), which failed to meet the 24% threshold for noninferiority.
The Takeaway: The authors were unable to prove that antibiotics were non-inferior to surgery in the management of uncomplicated acute appendicitis.