A long-term follow-up of the CODA Collaborative trial has shown that people managed conservatively with antibiotics for acute appendicitis often need surgery later on.^1,2 The trial findings are published in the New England Journal of Medicine and were also presented at the American College of Surgeons virtual clinical congress, which ends today.

The multicenter CODA (Comparison of Outcomes of Antibiotic Drugs and Appendectomy) trial enrolled 1552 patients with acute appendicitis, who presented to the emergency departments of 25 hospitals in the US between May 2016 and February 2020. The study participants either underwent immediate appendectomy or were treated with IV antibiotics for one day followed by oral antibiotics for 10 days. A total of 333 patients, earlier treated with antibiotics, developed recurrent appendicitis necessitating appendectomy; 94% of 297 patients had confirmed appendicitis on histopathology.

At one year, 40% of patients treated with antibiotics underwent appendectomy. This number increased to 46% in 2 years. Patients with an appendicolith were at higher risk of subsequent surgery. Compared to 40% of other patients treated with antibiotics, about half of the patients with an appendicolith had to undergo surgery within one year.

Preliminary 30-day results from the trial had been published last year, which reported a 2.28-fold higher complication rate for the antibiotic treated patients compared to those who underwent surgery; participants with an appendicolith were at a higher risk for complication. However, in this present long-term follow up study, complications were rate after 30 days. Among patients who had another appendicitis attack, the rate of perforation was comparable between the antibiotic treated group and surgically treated group; 20% vs 16%, respectively.

According to the study authors, these study findings “may make antibiotics a less desirable treatment”, nevertheless, many patients still opt for conservative treatment even though they may eventually need surgical treatment. This study further highlights informed consent and shared decision making between the treating doctor and the patients with appendicitis including those with an appendicolith.

Reference

1. CODA Collaborative. Antibiotics versus appendectomy for acute appendicitis -- longer-term outcomes. N Engl J Med 2021 October 25, 2021; DOI: 10.1056/NEJMc2116018.
2. Medpage Today News Release, October 25, 2021.