Journal Club Management of Appendicitis 9/15 /15 Matt Combs Dr. Lambing

Case You are a VCMC Grad fulfilling your calling as a Rural family med doctor working a graveyard shift in an ER with no in-house surgeon. An 18 yo M with no significant past medical history presents to your ER with 10hrs of worsening abdominal pain, N/V and decreased appetite. Started as peri-umbilical pain and moved toward the RLQ. He has a fever of 102F, WBC of 13,000 with a left shift and CRP 12. Abdomen is soft, with TTP over McBurney’s Point, minimal guarding. No rebound. Negative Rovsing’s sign.

Diagnosis Acute Appendicitis Alvarado Score: 8/10 AIR Score: 6/12

Background/Aim OF COURSE!! Management: Over 90% of time  surgery Question: Is surgery always the best decision? OF COURSE!!

Literature Search Key terms used Resources         Findings Appendicitis, Non-operative Management, Antibiotics, Surgery, Complications Resources         Pub Med Findings Many Studies: chose Meta Analysis

PICO Patient Population: Adults with uncomplicated(non-perforated/no abscess) acute appendicitis Intervention: Antibiotic Therapy Comparison: Surgery Outcome: Complications Design: Meta Analysis

Article “Safety and efficacy of antibiotics compared with appendectomy for treatment of uncomplicated acute appendicitis: meta analysis of randomized control trials” -British Medical Journal 4/2012 -Varadhan, Krishna. Et al. Hypothesis: Antibiotic therapy is superior to appendectomy (in terms of safety and efficacy) for treatment of uncomplicated acute appendicitis.

Design Meta Analysis of Randomized Control Trials 4 RCTs: Advantage: Larger N=greater statistical power Disadvantages: Heterogenicity of studies 4 RCTs: 900 patients (470ABx, 430 Appendectomy) Inclusion Criteria was variable: Adult uncomplicated appendicitis based on clinical signs (1/4 studies with radiographic confirmation by CT. ¾ with imaging optional ) Exclusion Criteria: Antibiotics prior to presentation Complicated Appendicitis Inflammatory Bowel Disease Women (x1 study) Allergies to Penicillin

Vons et al Hanson et al Styrud et al Eriksson et al Intervention -IV Augmentin x48hrs -If improved, D/C home with Augmentin x8 days -IV Cefotaxime + Flagyl x24 hrs -Discharged with Cipro + Flagyl x 10 days -IV Cefotaxime + Tinidazole x48hrs -Surg if no improvement after 24hrs -Discharged with Ofloxacin and Tinidazole x10 days -IV Cefotaxime +Tinidazole x48hrs -Discharged with Ofloxacin + Tinidazole Control Surgery w/ Augmentin pre-op Surgery. Abx at surgeons discretion Surgery. Abx at Surgeons discretion Outcomes Peritonitis within 30 days of treatment Efficacy, complications, recurrences, length of stay Length of stay, recurrence, complications Wound infections, recurrence, pain

Outcome Measures

Complications

Results Based on Primary Outcome: Complications Relative Risk Reduction All 4 trials 29% Excluding Crossover 39% Event rate Antibiotics All 4 trials 17.87% Excluding Crossover 11.57% Surgery 25.12% 19.01% Absolute Risk Reduction All 4 Trials 7.25% Excluding Crossover 7.44% Number Needed to Treat All 4 Trials 13.79 Excluding Crossover 13.44

Results: AntibioticsSurgery 20% (68/345) of patients originally treated with Antibiotics were readmitted and 65 ended up having appendectomy

Other Results Treatment Efficacy Length of Hospital Stay “A simple comparison of efficacy for treatment between two entirely different treatments such as surgery and antibiotics for which treatment failure is a possibility would not be truly appropriate” Essentially, both treatment arms were 100% successful at 1 year. Length of Hospital Stay No statistically significant difference P=0.20

Critique Downfalls of this Article Strengths…. Heterogenicity of studies!! GRADE Analysis: overall quality of evidence low-moderate Radiographic confirmation in ¾ studies Different antibiotics in all 4 studies Crossover in treatment groups Unknown if prophylactic antibiotics given prior to surgery Strengths…. There is power in numbers (high N value)

Application: At home and Abroad At VCMC: Consider initial conservative treatment Global Perspective: Lack of availability of ORs/surgeons Cost (Surgery>>>>>Antibiotics) Abx appear to be a reasonable initial option although more high quality studies need to be performed

Summary Meta-analysis of mediocre studies indicating fewer complications in patient with acute uncomplicated appendicitis treated with antibiotics vs those treated initially with appendectomy