A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

CODA Collaborative, Flum DR, Davidson GH, Monsell SE, et al. N Engl J Med. 2020 Oct 5. Epub ahead of print. [CrossRef] [PubMed]

Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. The authors conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days. In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The authors conclude that for the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.