Stanford, CA—In the last decade or so, pharmacists increasingly have found themselves filling prescriptions for antibiotics to treat appendicitis, instead of the condition being treated with surgery.

A new study published online by JAMA Surgery suggests that that might not be a good idea, after all. Stanford University School of Medicine researchers found that treating appendicitis with antibiotics instead of surgically removing the inflamed organ was costlier and resulted in higher rates of hospital readmissions.

“People treated with antibiotics alone have a higher chance of coming back needing further treatment for appendicitis-related problems, such as abdominal abscesses,” explained lead author Lindsay Sceats, MD, a surgical resident. “They also have a higher risk of having a reoccurrence, and the cost is no lower.”

Background information in the article notes that appendectomy traditionally has been the standard treatment, but some physicians have begun offering drug therapy as an alternative, primarily to patients who are poor candidates for surgery. That practice was supported by several European studies showing positive outcomes, according to the report, including one from Finland published in JAMA this fall.

“More and more patients in the Stanford emergency room have been asking about whether they can just take antibiotics when they come in with appendicitis instead of having surgery,” Sceats points out, adding that the study was designed to determine whether drug treatment really is a good alternative.

Using claims data from a private insurance database, the national retrospective cohort study compared patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, who were undergoing appendectomy versus nonoperative management.

With data analyzed from February 12, 2018 through May 1, 2018, researchers focused on short-term primary clinical outcomes, including emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections, as well as long-term primary clinical outcomes such as small-bowel obstructions, incisional hernias, and appendiceal cancers.

Nonoperative management failure was defined by hospital readmission with an appendicitis diagnosis and an appendicitis-associated operation or procedure, whereas secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care.

Of 58,329 patients with uncomplicated appendicitis, the average age was 31.9 years and 52.7% were men; 95.5% underwent appendectomy and 4.5% were managed nonoperatively. Results suggest that patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P <.001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02).

Those patients also required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs. 0.3 [1.4] visits; adjusted +1.11 visits; P <.001) and had a lower index hospitalization cost (unadjusted mean [SD], $11,502 [$9,287] vs. $13,551 [$10,160]; adjusted -$2,117, P <.001).

These patients’ total cost of appendicitis care was higher, however, when follow-up care was considered (unadjusted, $14,934 [$31,122] vs. $14,186 [$10,889]; adjusted +$785; P = .003), the researchers point out.

The study team determined that, during a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%). Median time to recurrence was calculated as 42 days (interquartile range, 8-125 days), although 44 patients experiencing treatment failure did so within 30 days.

“Even if the initial hospitalization is cheaper, when you look at long-term cost, which our study did, it ends up being more expensive,” Sceats said. “These results tell us that, in most cases, surgery is still the best strategy. For your average, healthy 30-year-old, the alternative treatment is no cheaper, and it’s easier to have the surgery. You also no longer have an appendix, so you’re no longer at risk of having appendicitis again.”

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