Appendicolith, an important factor for deciding which patients will require appendectomy: JAMA
USA: Assessing appendicolith status may be informative for patients considering antibiotics who want to better understand their chance of appendectomy, suggests a recent study in the journal JAMA Surgery.
The results derived from secondary analysis of the CODA trial showed that radiographic findings, especially appendicolith, were related to a 2-fold increased risk of undergoing appendectomy within 30 days of starting antibiotics for treating acute appendicitis. Further, clinical characteristics used often to describe appendicitis severity were not associated with odds of 30-day appendectomy.
Antibiotics use for appendicitis treatment are safe and have been shown to be noninferior to appendectomy based on self-reported health status at 30 days. More individualized decision-making could be made by identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics.
Against the above background, David Flum, the University of Washington in Seattle, and colleagues aimed to assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis.
For this purpose, the researchers compared characteristics among patients who initiated antibiotics between those who did and did not undergo appendectomy within 30 days using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial. The study, conducted at 25 US medical centers, enrolled participants between May 3, 2016, and February 5, 2020.
A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Of 776 participants initiating antibiotics (mean age, 38.3 years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days.
The associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics were estimated. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for non-clinical reasons.
The study revealed the following findings:
- After adjustment for other factors, female sex (odds ratio [OR], 1.53), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09), and presence of appendicolith (OR, 1.99) were associated with increased odds of undergoing appendectomy within 30 days.
- Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28) were not associated with odds of 30-day appendectomy.
- The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41).
To conclude, the presence of an appendicolith was found to be associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics.
"Clinical characteristics often used to describe the severity of appendicitis were not associated with odds of 30-day appendectomy," the authors wrote. "This information may help guide more individualized decision-making for people with appendicitis."
Reference:
Writing Group for the CODA Collaborative. Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis. JAMA Surg. Published online January 12, 2022. doi:10.1001/jamasurg.2021.6900
