October 5, 2020

Treating appendicitis with antibiotics instead of surgery may be good option for some, but not all, patients

Antibiotics instead of surgery may be a good choice for some, but not all, patients with appendicitis, according to results from a study reported today in the New England Journal of Medicine.


by Nancy Humphrey

Antibiotics instead of surgery may be a good choice for some, but not all, patients with appendicitis, according to results from a study reported today in the New England Journal of Medicine.

The study compared immediate surgery for appendicitis against an alternative approach that used antibiotics initially to treat it, then only moved to surgery if the antibiotics strategy wasn’t working.

Comparing Outcomes of antibiotic Drugs and Appendectomy (CODA) is the largest randomized controlled clinical trial of appendicitis to date. It included 1,552 participants from 25 participating sites in 14 states and included Vanderbilt University Medical Center.

In the study, after three months, 7 of 10 participants (70%) randomized to the antibiotics strategy avoided an operation and 30% underwent surgery due to the perception that the antibiotics were not working. The authors concluded that treating appendicitis is definitely not a one-size-fits-all approach.

Surgical removal of the appendix, an appendectomy, has been the standard of care for treatment of appendicitis for more than 120 years, but treatment with antibiotics is often proposed as an alternative.

Wesley Self, MD, MPH

The participants were randomized to receive either appendectomy or antibiotics first for uncomplicated appendicitis.

“The results of this trial are very useful as doctors talk to patients about treatment options for appendicitis,” said Wesley Self, MD, MPH, vice chair for Research in the Department of Emergency Medicine at VUMC and an author of the study. “It appears that an antibiotics-first approach can lead to some patients recovering from appendicitis without surgery, but that approach certainly doesn’t work for everyone. For example, patients who have appendicitis with an appendicolith, a firm stone-like material inside the appendix, appear to frequently fail the antibiotics treatment approach.”

The results of this study can be important for individuals with appendicitis as they, with their physician, determine the best treatment option, the study shows.

“The best treatment option may depend on patient preference; some patients may want to have immediate surgery to definitively take care of the problem, knowing it may take them some time to recover after the surgery. On the other hand, other patients may choose the antibiotics strategy to see if they can avoid surgery, realizing the antibiotics approach may not work and they would need to come back to the hospital for surgery.” Self said.

While nearly half of the antibiotics group avoided hospitalization for their initial treatment, overall, the time spent in the hospital was similar between groups and patients treated with either surgery or antibiotics experienced symptoms for about the same length of time. Patients treated with immediate surgery missed more days of work on average than those treated with the antibiotics approach. But a lower proportion of patients treated with immediate surgery came back to the hospital after the initial treatment course,” Self said.

The trial was completed one month before the first cases of COVID-19 were identified in the United States. With the COVID-19 pandemic, health systems and professional societies such as the American College of Surgeons have been reconsidering many aspects of health care delivery, including the treatment of appendicitis.

The trial was funded by Patient-Centered Outcomes Research Institute (PCORI). The CODA Collaborative is composed of clinicians (surgeons and emergency physicians) at each of the 25 trial sites, patient advisors and other stakeholders.

“It’s essential to have both surgeons and emergency physicians working together because both specialties are central to diagnosing and treating patients with appendicitis. Successful collaboration across specialties was essential to make this trial a success,” Self said.