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Ann Emerg Med. 2017 Jul;70(1):1-11.e9. doi: 10.1016/j.annemergmed.2016.08.446. Epub 2016 Dec 11.

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management.

Author information

1
Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA. Electronic address: dtalan@ucla.edu.
2
Department of Surgery, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
3
Department of Emergency Medicine, Ronald Reagan Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
4
Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
5
Department of Radiology, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
6
Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
7
Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
8
Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Abstract

STUDY OBJECTIVE:

Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics-first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics-first, including outpatient management, with appendectomy.

METHODS:

Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics-first-treated participants older than 13 years could be discharged after greater than or equal to 6-hour emergency department (ED) observation with next-day follow-up. Outcomes included 1-month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics-first appendectomy rate.

RESULTS:

Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics-first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/μL (range 6,200 to 23,100/μL), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic-treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics-first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics-first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics-first-treated participants had less pain and disability. During median 12-month follow-up, 2 of 15 antibiotics-first-treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group.

CONCLUSION:

A multicenter US trial comparing antibiotics-first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.

PMID:
27974169
PMCID:
PMC5616169
DOI:
10.1016/j.annemergmed.2016.08.446
[Indexed for MEDLINE]
Free PMC Article

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