This week’s New England Journal of Medicine weighs in on the growing trend of treating appendicitis with antibiotics alone, rather than urgent surgery.
I’ve seen this trend—in fact, at one hospital where I worked last year, the surgeons were extraordinarily hesitant to take a variety of patients to surgery, strongly preferring prolonged antibiotics in lieu of surgery. It was a quite jarring perspective for me.
The choice of treatments—antibiotics or surgery—is an important issue, as 7-14% of people will develop appendicitis at some point and 30,000 people undergo appendectomy each year in the U.S.
The author, Dr. David Flum of the University of Washington, reviews strategies for diagnosing appendicitis based on symptoms, labs, and X-rays, noting that CAT scans have a sensitivity and specificity greater than 90%.
Surgery is most often done laparoscopically (less invasive than the old-fashioned open surgery), with a complication rate of 1-3%. The skin infection rate is 3.3% vs. 6.7% with open surgery.
The new trend is to treat with antibiotics alone, especially in Europe. Unfortunately, up to 37% of patients randomly assigned to this treatment in studies have needed an appendectomy in less than a year. Dr. Flum notes a typical treatment option is 48 hours of IV antibiotics followed by a week of oral Ciprofloxacin, a quinolone antibiotic, and Flagyl (metronidazole). The author makes an excellent point that experience with antibiotic therapy alone may not be this good outside of studies, as patients may not adhere to the full course of treatment, especially as both of these antibiotics often cause nausea. He also notes that cost analyses fail to account for cost of caregiver support and potential complications, focusing mostly on initial surgery.
The surgical societies cited all recommend surgery as the preferred treatment; I, as an internist, agree.
The European experience reported does not match mine, though mine is more limited now. Patients have sometimes been kept in the hospital for days, far longer than the typical 2-3 day course following surgery. The antibiotics-first approach makes sense to me for elderly patients or those at significant risk of surgical complications (e.g., previous abdominal surgeries, heart or lung disease), but not for uncomplicated appendicitis in the young or healthy.
There are factors not mentioned in this review that, given the perspective of my specialty, I believe need to be addressed. First, as an infectious disease physician, I always encourage my surgical colleagues to obtain intraoperative cultures to guide antibiotic choices. Even in low risk patients from the community, I have been surprised to see Pseudomonas in intra-abdominal cultures. Resistance is increasing dramatically, and it is important to know the patient’s microbial flora. While quinolones are the most commonly prescribed class of antibiotics in the U.S., I would be loath to treat with oral ciprofloxacin. The Center for Disease Dynamics, Economics & Policy (CDDEP) reports that E. coli, the major Gram negative bacteria in the bowel, had 37% resistance in East South Central US in 2010, and 20% in mid-Atlantic. In Asia, the resistance rates are far higher, regularly over 60% of intra-abdominal isolates, and 77% in India.
If Cipro is not used, Augmentin (Ampicillin-Clavulante) is sometimes given, but it will miss many resistant organisms and is known for causing diarrhea. There are no other good oral antibiotic options, and the patient will likely need a PICC line (Peripherally Inserted Central Catheter) to receive home IV antibiotics. There are significant risks to PICC lines, and they are used far to often, because hospitals focus on getting patients out so quickly, to improve their profit, and home health agencies insist on PICC lines for OPAT (Outpatient Antibiotic Therapy), rather than the small IVs in the wrist or forearm used initially in the hospital. Dr. Vineet Chopra details the issues in a review, noting: PICCs carry risk of bloodstream infection, especially in cancer patients (1.1 vs. 1.8 to 7.7 per 1000 PICC days). The bloodstream infections carry an estimated risk of death of 12%-25% (without cancer) to 31-36% (with cancer). Similarly, blood clots are a significant risk (>2.5%, higher in patients with prior clots or cancer, or with use of larger catheter in particular).
The other huge problem with antibiotic therapy alone is that the prolonged administration of antibiotics increases the risk of side effects and also promotes antibiotic resistance. Quinolones are associated with increased risk of acquiring ESBL resistant organisms and promote methicillin resistance among Staphylococci.
As Dr. Flum notes, there are many more factors that should be examined before more broadly recommending antibiotics in lieu of appendectomy. I welcome his call for more clinical trials and for physicians to include their experience in a clinical trial registry, such as that sponsored by the U. of Washington and UCLA.
While antibiotic treatment alone appears to be a viable option, I agree that surgery is still the best option for most patients. I would go a bit further and recommend that the “antibiotics first” pathway should only be tried in patients who have significant underlying medical problems that make surgery riskier. Most importantly, I would suggest that the risk to the patient and the community of breeding antibiotic resistant organisms, adverse events from more prolonged antibiotic treatment, and complications from otherwise unnecessary central intravenous catheters be included in further research. The risks of “antibiotics first” are more nuanced than are commonly considered and affect us all.
