A new analysis found that outpatient management of appendicitis with antibiotics is safe for selected patients, which may allow people to avoid hospitalization and surgery.
Historically, treatment for appendicitis has always been surgery — but there’s growing evidence that it’s safe to treat with antibiotics alone for some patients, even from the comfort of their own home. Researchers found that outpatient antibiotic management was not associated with more complications or later appendectomies. The findings were published in JAMA Network Open earlier this month by researchers at the Ronald Reagan UCLA Medical Center.
It could have important implications for the treatment of appendicitis and give patients more options, experts told TODAY.
The study was a secondary analysis of the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, the largest randomized controlled trial comparing antibiotic treatment and appendectomy, Dr. David Talan, professor of emergency medicine at University of California, Los Angeles, and lead study author, told TODAY.
Appendicitis refers to inflammation of the appendix, which sticks off from the colon in the lower right part of the abdomen and is about the size of the little finger, Talan said. “We think it gets inflamed due to infection,” which can be caused by bacteria, viruses or parasites, he continued. Untreated appendicitis can cause the appendix to rupture, which can be life-threatening. Treatment is typically surgery to remove the appendix, aka an appendectomy, Talan said. There are 250,000 cases of appendicitis in the U.S. each year.
By the early 1900s, thanks to the advent of anesthesia, it was routine to remove the appendix at the first sign of appendicitis and to give antibiotics after surgery to decrease the risk of postoperative infections, “but no one thought hey, let’s try antibiotics instead of surgery," until several decades later, Talan said.
Today, imaging like CT scans allow doctors to accurately diagnose appendicitis, as well as its stage, said Talan. Most people present with appendicitis in the early stage, also be called localized or uncomplicated appendicitis, he added.
“People started to do clinical trials comparing just giving antibiotics versus the routine, urgent appendectomy,” Talan said. The CODA trial, the biggest of these, compared a 10-day course of antibiotics with appendectomy in patients across 25 U.S. hospitals. From May 2016 to February 2020, 1,552 adults with acute appendicitis were randomized to receive either antibiotics or an appendectomy. The study found that antibiotics were not inferior to appendectomy in selected patients, said Talan, co-principal investigator of the CODA trial.
This new study looked at the safety of outpatient management among the patients in the CODA trial who were assigned to get antibiotics, Talan said.
“As long as the patients were responsible, if the doctors felt that they were stable, their pain was controlled, their medical condition hadn’t worsened … the doctors were allowed to send those people home on oral antibiotics to be treated outside the hospital,” Talan explained.
Researchers looked at the incidence of serious adverse events, such as death, life-threatening events, treatment-related disability and unrelated hospitalization, among these patients, and also compared health outcomes, urgent care visits and later appendectomies, as appendicitis can return after treatment with antibiotics, Talan said.
The study found that of the 726 participants who received antibiotics, 46% who met stability criteria were discharged within 24 hours, and outpatient management was associated with less than one serious adverse event per 100 participants during the first seven days after discharge.
People who received outpatient antibiotics did not have a higher incidence of appendectomies in the first week or at 30 days compared to those who were hospitalized. “Less than 5% of outpatient-treated participants returned for unplanned outpatient care,” the study authors wrote.
“We found it was safe … because the rates of (serious adverse events) were no greater. In fact, there was a trend towards both the (serious adverse events) and the later appendectomies being less among those who felt stable to go home,” Talan said. The study authors concluded that most patients who choose antibiotics can avoid hospitalization and complete treatment at home “without incurring increased risk of serious complications or appendectomy.”
Appendectomies are still routine even though antibiotics are a safe first-line alternative, Talan said, but at least for now, patients with uncomplicated appendicitis have more options. “For 120 years, we’ve put people in the hospital and taken them to surgery. And now it looks like people can avoid surgery, and even be at home and get over this condition,” said Talan.
As the study authors wrote, this option should be included when health care providers walk patients with appendicitis through their treatment options. “We have two approaches that are safe, but they have different advantages and disadvantages. … The best approach for you is the one whose outcomes you most value,” said Talan.
Avoiding surgery and hospitalization may be an attractive and cost-effective option for many people. According to the study authors, outpatient antibiotic treatment could help patients miss less work and decrease health care costs for appendicitis.
“These trials don’t tell us that there’s one better way to treat appendicitis. … They tell us that you have options, and each option has its own risks,” Dr. F. Perry Wilson, associate professor at Yale School of Medicine who was not involved in the study, told TODAY.
Appendicitis used to be a uniformly a surgical diagnosis, but “what is being found is that a significant number of these cases, perhaps even a majority, can be managed with antibiotics,” said Wilson.
That said, it's not the remedy for all situations, and sometimes, surgery is the only option, as antibiotics won't prevent appendicitis from happening again. “For a lot of these people, even if the appendicitis gets better, they might have recurrent appendicitis which is going to require surgery,” Wilson said.
It’s important to note that all of the study participants had uncomplicated appendicitis. “There was a screening process to make sure that they weren’t too sick to get antibiotics … so this wouldn’t apply to people who have sepsis for example,” he said.
“We’re still going to see a lot of surgery for appendicitis. This (study) doesn’t take that away at this point in time, but it does certainly give some breathing room to people … and one more option in treatment if you’re willing to accept the risks and responsibilities."