Antibiotics are an effective first-line treatment for most cases of appendicitis, according to the American College of Surgeons.

The decision is based on the results from the Comparing Outcomes of antibiotic Drugs and Appendectomy (CODA) trial, the largest randomized medical trial of appendicitis treatments ever performed. It included 25 hospitals across 14 states, totaling 1,552 patients with appendicitis. These participants were then randomized to undergo an appendectomy (surgery to remove the appendix) or follow an antibiotics course.

While both approaches had their advantages and downsides, the overall conclusion of the CODA trial is that both are safe to use and efficient in treating the condition.

Noninvasive is fine

“In the first three months after taking antibiotics for the condition, nearly 7 in 10 patients in the antibiotic group avoided an appendectomy. By four years, just under 50% had the surgery,” said Dr. David Flum, co-principal investigator and professor and associate chair of surgery at the University of Washington (UW) School of Medicine. “Other outcomes favored either antibiotics or surgery. Putting it all together, antibiotics look to be the right treatment for many, but probably not all, patients with appendicitis.”

“While there were advantages and disadvantages to each treatment, we found that both treatments are safe, and patients will likely value these outcomes differently based on their unique symptoms, concerns, and circumstances,” he adds.

The authors note that one of the most important factors regarding the efficacy of antibiotics for these patients was the presence of appendicoliths, calcified deposits found in about one-quarter of patients with acute appendicitis. Patients with appendicoliths had a higher chance of experiencing complications and a higher likelihood of needing an appendectomy during the first 30 days of treatment than their peers.

However, by the 90-day mark, this group of patients had no greater chance of needing an appendectomy than other appendicitis patients enrolled in the trial.

The percentage of patients in the antibiotics group who later underwent appendectomy was 40% at 1 year and 46% at the 2-year mark. This percentage was higher in patients with appendicoliths.

Overall, however, these findings are quite encouraging. Appendicitis is generally treated as an emergency, and the standard treatment approach is surgery, to have it removed. In most cases, even the suspicion that a patient might have appendicitis is cause enough for a doctor to send them into surgery, in a bid to avoid the possible complications caused by the rupturing of an inflamed appendix.

Needless to say, nobody likes undergoing surgery. The results of this trial show that antibiotics are an effective treatment option for a majority of cases. Patients and doctors should work together to discuss the best treatment approach. On the one hand, this would help improve the quality of life for appendicitis patients; on the other, it will free up medical resources which can be used on other essential surgeries.

“Given these results and new treatment guidelines, it is important for surgeons and patients to discuss the pros and cons of both surgery and antibiotics in deciding on the treatment that’s best for that person at that time,” said Dr. Giana Davidson, associate professor of surgery at UW and director of the CODA trial’s clinical coordinating center.

Towards that end, the CODA team put together an online decision-making tool for patients (http://www.appyornot.org) to help them better decide what option is right for them. The site includes videos in English and Spanish discussing the issue — other languages will be included in the future — to help inform them on the nuances of this choice.

“In the emergency setting, patients with appendicitis can make a treatment decision hurriedly,” Davidson said. “This online tool was built to help communicate the CODA results in laymen’s terms, and to spur a conversation between patients and surgeons about potential benefits and harms of each approach.”

The paper “Antibiotics versus Appendectomy for Acute Appendicitis — Longer-Term Outcomes” has been published in The New England Journal of Medicine.