Antibiotics instead of surgery better choice only for some in Appendicitis: NEJM study

In fact antibiotics may be a good choice for some, but not all, patients with appendicitis, according to results from the Comparing Outcomes of antibiotic Drugs and Appendectomy (CODA) Trial reported in the New England Journal of Medicine.

This was the first multicenter U.S. trial to study appendicitis treatment, and it assessed a diverse population in addition to a wider variety of appendicitis than previous trials," said Mike Liang, MD, associate professor of surgery with McGovern Medical School at UTHealth, who was the principal investigator at Harris Health's Lyndon B. Johnson Hospital, which was one of the largest enrolling sites of the 25 across the country that participated in the trial.

The findings indicated that antibiotics were not worse than surgery when measuring overall health status, allowing most people to avoid an operation in the short term. Boston Medical Center, one of 25 hospitals nationwide where the CODA Trial was conducted, recruited the greatest number of patients among the three New England CODA sites and was in the top third for patient recruitment overall.

"There were advantages and disadvantages to both treatments, and patients are likely to prioritize these in different ways based on their own unique characteristics and interests," said F. Thurston Drake, MD, MPH, a general and endocrine surgeon at Boston Medical Center (BMC) who served as co-site lead for CODA at BMC. "As a surgeon, I can play an important role in helping patients choose the treatment options that are best for their individual situation and health needs."

While nearly half of the antibiotics group avoided hospitalization for their initial treatment, overall, the time spent in the hospital was similar between groups. "People treated with antibiotics more often returned to the emergency department but missed less time from work and school," said Bonnie Bizzell, chair of the CODA Patient Advisory Board. "Information like this can be important for individuals as they consider the best treatment option for their unique circumstance. The CODA Trial is really the first of its kind to capture these measures for appendicitis shared decision-making."

The CODA Trial, which was funded by the Patient-Centered Outcomes Research Institute (PCORI), is the largest randomized clinical trial of appendicitis conducted to date. Across the United States, 1,552 participants were randomized to receive appendectomy or antibiotics-first for uncomplicated appendicitis.

Other initial findings of the CODA Trial include:

Patients treated with either surgery or antibiotics experienced symptoms of appendicitis for about the same amount of time.

Approximately 3 out of 10 patients in the antibiotic group underwent appendectomy by 90 days.

Patients with an appendicolith, a calcified deposit within the appendix, had twice the risk of complications than those without an appendicolith.

Participants with an appendicolith had an increased chance of appendectomy by 90 days (4 in 10 with appendicolith vs 3 in 10 without).

"The results from this trial provide tremendous insight into how providers and patients can collaborate and develop treatment plans based on the options available and the needs of the patient," added Sabrina E. Sanchez, MD, MPH, a surgeon at BMC who co-led the BMC CODA trial site. "Patients are key players when determining their care plans, and their insight can lead to tailored treatment options based on their specific needs, which can improve health outcomes."

The CODA Collaborative, composed of clinicians at each of the 25 CODA Trial sites, patient advisors, and other stakeholders, will continue to share results from the trial as ongoing follow-up with participants is completed. The CODA Trial was led by Co-Principal Investigators David Flum, MD, MPH, professor and associate chair of the department of surgery at the University of Washington and David Talan, MD, professor of emergency medicine and medicine/infectious diseases at the David Geffen School of Medicine at UCLA.