Outpatient antibiotic treatment safe for selected adults with acute appendicitis

Outpatient antibiotic treatment was safe compared to hospital care, with no greater risk of complications or appendectomy, in a subgroup of patients with acute appendicitis, according to research.

“The Comparison of the Results of” Antibiotics and Appendectomy (CODA) study was the largest reported randomized clinical trial comparing antibiotic treatment and appendectomy for patients with imaging-confirmed appendicitis. The CODA study found that antibiotics were not inferior to appendectomy for a 30-day overall health measure, the EuroQol 5 dimension (EQ-5D) score,” David A. Talan, MD, of the emergency medicine department at Ronald Reagan UCLA Medical Center, and colleagues wrote: JAMA network opened† “In 2020, following the publication of the first results of the CODA study, the American College of Surgeons issued guidelines stating that high-quality evidence indicates that most patients can be treated with antibiotics instead of appendectomy. Outpatient treatment, if safe and effective, may offer greater convenience for the patient and less use of care and lower costs.”

In a secondary analysis cohort study, Talan and colleagues examined the use and safety of outpatient treatment in 776 patients with appendicitis who received antibiotics at 25 U.S. hospitals from May 2016 to February 2020. Researchers defined outpatient treatment and hospitalization as discharge within or after 24 hours. , respectively.

Of the participants randomized to receive antibiotics, 5.4% had appendectomy within 24 hours and 1% did not receive their first antibiotic dose within 24 hours. Of the remaining 726 patients (median age, 36 years; 63.6% male; 60.2% Caucasian), 46.1% were discharged within 24 hours, while 53.9% were discharged after 24 hours.

Serious adverse reactions were reported for 7 days in 0.9 (95% CI, 0.2-2.6) per 100 participants discharged within 24 hours and 1.3 (95% CI, 0.4-2, 9) per 100 participants who were discharged after 24 hours. In a subgroup of patients with appendicolite, serious adverse events occurred in 2.3 (95% CI 0.3-8.2) and 2.8 (95% CI 0.6-7.9) per 100 participants, respectively.

Further analysis showed the incidence of appendectomy at 7 days in 9.9% of outpatients (95% CI, 6.9-13.7) and 14.1% of inpatients (95% CI, 10.8- 18). At 30 days, 12.6% (95% CI, 9.1-16.7) and 19% (95% CI, 15.1-23.4) underwent appendectomy, respectively.

Overall, both patient groups reported low rates of treatment dissatisfaction and equally high EQ-5D scores at 30 days, with National Surgical Quality Improvement Program events occurring in 1.8 (95% CI, 0.8-3.9 ) per 100 outpatients and 5.6 (95% CI), 3.5-8.5) per 100 hospitalized patients. Outpatients also missed fewer work days (2.6 days; 95% CI, 2.3-2.9) compared to hospitalized patients (3.8 days; 95% CI, 3.4-4, 3).

“The findings of this cohort study support that outpatient antibiotic treatment is safe for selected adults with acute appendicitis. It appears that most patients who choose antibiotics can avoid hospitalization without an increased risk of serious complications or appendectomy,” concluded Talan and colleagues. “Outpatient management should be incorporated into shared decision-making discussions about patients’ preferences for outcomes related to nonoperative and operative care.”