Antibiotics vs Surgery in Appendicitis

Dr. Erik Fossen

Background


The inspiration behind choosing this article came from a case I had in the Emergency Department involving acute uncomplicated appendicitis. The patient was a 30-year-old male who did not want to be admitted for surgery because he had too many obligations at work and at home. He asked if there was an outpatient option that would allow him to defer the appendectomy to a later date.

Article


Talan MD, David A, et. al. “Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management.” Annals of Emergency Medicine: July 2017, Vol 70, Iss 1: 1-9.



Study Design




Small single center randomized control trial that looked at patients 5 years of age and older with uncomplicated appendicitis. Patients were randomized to either appendectomy or the antibiotic protocol, which entailed intravenous ertapenem for 48hrs or more and oral metronidazole and cefdinir. The first dose of ertapenem was given within 6 hours of being in the Emergency Department. During this 6-hour observation period, five parameters were considered for stable discharge:

  1. SBP > 90, HR < 100, Temp < 38.5

  2. Pain controlled with oral analgesics

  3. Toleration of oral fluids

  4. Reliable follow up established

  5. Physician and patient’s comfort with being discharged


Patients older than 13 that were treated with antibiotics could be discharged following the observation period if they were stable. These patients were to return the following day to get their second dose of ertapenem before being discharged with oral metronidazole and cefdinir for 8 days. Those who were not stable following the 6-hour initial observation period in the ED were hospitalized and received their second dose of ertapenem while inpatient. They were also discharged with the same oral antibiotic regimen.

Some patients were transitioned to the appendectomy group if the following were present after two doses of ertapenem had already been administered:

  1. Peritonitis present or serial abdominal exams not improving (evaluation by surgeon)

  2. Severe sepsis

  3. Temp > 38.5, WBC < 4K or >15K

  4. Consent obtained for surgery


Antibiotic Group


  • 14 of the 15 adult patients met the stable discharge criteria. The one adult that was admitted was discharged the next day following administration of his second ertapenem dose. One pediatric patient was also admitted for antibiotics.

  • There was one re-occurrence of appendicitis 18 days out that was successfully treated with antibiotics.

  • At one year follow up, 2 patients had re-occurrence of appendicitis and one required an appendectomy. The other received antibiotics.

  • Secondary outcomes showed shorter interval to being pain free, decrease in overall hospital time and quicker return to baseline activity.



Appendectomy Group


  • Laparoscopic surgery performed on 9 of 14 patients (64%) and open appendectomy performed on 5 of 14 patients (36%).

  • The two major complications of surgery included trocar induced retroperitoneal hemorrhage requiring a blood transfusion and post-operative abscess 5 days following surgery requiring drainage.

  • No major complications found 1 year out.



Using antibiotics first to treat uncomplicated appendicitis over appendectomy may be a feasible option.



Bomb


Will this change my practice? No.

This concept needs to be evaluated on a larger, multi-center scale to really determine safety and efficacy before it can be considered practice-changing. Standard of care is to treat appendicitis as a surgical disease, which needs definitive surgical management. Disposition in the ED also becomes an issue, given that a 6-hour observation period is needed to make a clinical decision with the proposed antibiotic protocol in this particular study. If the patient is discharged from the ED there is another dose of ertapenem that must be given IV and this can be difficult to arrange.



Discussion