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

2. 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.

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

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

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

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

7. 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.

8. 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

9. 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

10. Outcome Measures

11. Complications

12. 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

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

14. 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

15. 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)

16. 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

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