Antibiotics Safe for Some Outpatients With Acute Appendicitis

Select patients with acute appendicitis who were discharged from the hospital within 24 hours were safely managed with antibiotics as outpatients, a secondary analysis of the CODA Collaborative trial found.

Among over 700 patients, serious adverse events occurred in 0.9 per 100 outpatients compared with 1.3 per 100 inpatients over 7 days, reported David Talan, MD, of the Ronald Reagan UCLA Medical Center in Los Angeles, and colleagues.

Within 30 days, serious adverse events occurred in 1.8 per 100 outpatients and 3.1 per 100 inpatients, the authors noted in JAMA Network Open.

In addition, significantly fewer outpatients treated with antibiotics required an appendectomy at 30 days versus inpatients (12.6% vs 19.0%).

Outpatients also missed fewer weekly workdays (2.6 vs 3.8 days), and reported similar satisfaction with their selected treatment compared with the hospitalized group, with a similar frequency of return healthcare visits at 7 days and similarly high quality-of-life scores at 30 days (mean EuroQol 5-dimension score 0.93 vs 0.92, respectively).

“Most patients with appendicitis can be treated with antibiotics instead of surgery, and most of those who choose this type of care can be safely treated as an outpatient, usually avoiding hospitalization and surgery,” Talan told MedPage Today. “Outpatient management appeared safe in up to 90% of patients with appendicitis.”

“In today’s complex medical environment, the focus should always be on optimal clinical outcomes and the delivery of the highest-value healthcare,” said Diya Alaedeen, MD, of the Cleveland Clinic in Ohio. “This sub-study of the CODA trial, while it has its own limitations, may set the stage for a new paradigm shift in treating highly selected patients with appendicitis in an outpatient setting, hence changing the narrative on appendicitis from that of an emergent surgical disease to that of treat and release.”

The open-label CODA trial showed that antibiotics were noninferior to appendectomy, Talan’s group noted. In 2020, the American College of Surgeons released guidelines that recommended that most uncomplicated appendicitis patients be treated with antibiotics rather than an appendectomy during the COVID-19 pandemic.

However, follow-up data from CODA showed that patients often required an appendectomy after antibiotics. Furthermore, the presence of an appendicolith may increase the risk for surgery within 30 days of initiating antibiotics.

For this secondary analysis, Talan and colleagues examined data on 726 patients with imaging-confirmed appendicitis across 25 U.S. hospitals from May 2016 to February 2020. Median patient age was 36 years, 63.6% were men, and 60.2% were white.

Of the 726 patients, 335 were discharged within 24 hours and 391 were discharged after 24 hours.

Analyses were adjusted for age, fever, Charlson Comorbidity Index, Alvarado score, nausea/vomiting, pain score, and appendicolith on imaging, among other factors, but did not address unmeasured differences, such as clinical symptom changes.

In the appendicolith subgroup, serious adverse events occurred in 2.3 per 100 outpatients compared with 2.8 per 100 inpatients over 7 days.

There were no reported deaths in either group.

Talan and team acknowledged that unaccounted factors may have differentiated patients discharged early from the hospitalized group. Moreover, since this was not a randomized trial in which patients were assigned to early discharge or inpatient care, they did not directly assess comparative effectiveness, they said.