Introduction: Appendectomy has been the gold standard therapy for management of acute appendicitis. Recent randomized control trials (RCTs) have supported the efficacy of antibiotics as a first line of treatment for acute appendicitis, while others supported surgery as more efficacious. As RTC treatment efficacy may not reflect actual practice effectiveness, our aim was to compare the clinical effectiveness of appendectomy-first versus and antibiotic-first strategy.
Methods: Data was collected through the Florida Agency for Health Care Administration (AHCA) hospital discharge records 2019-2021. Patients >18 years old with a principal diagnosis of acute appendicitis were identified using ICD-10 diagnosis codes, excluding those with abscess on admission. The 22,915 patients were categorized using ICD-10 procedure codes. The antibiotic-first treatment patients (Group 1) were those not undergoing an appendectomy or undergoing an appendectomy on day >6 of hospital stay. Patients in this group who had an appendectomy were considered to have a failed antibiotic course. The appendectomy-first patients (Group 2) had an appendectomy as the initial treatment within 1 day of admission. The indeterminate patients (Group 3) included patients who had an appendectomy 2 to 5 days of admission. Efficacy was evaluated in terms of LOS, number of complications, complication rate, and the development of an abdominal abscess. Complications were defined as any new hospital diagnosis not present on admission.
Results: A majority of patients received an appendectomy to treat their uncomplicated acute appendicitis (91.6%). There was an 18.3% complication rate in the antibiotic treatment group, a 15.9% complication rate in the appendectomy treatment group, and a 28.1% complication rate in the indeterminant group[VV1] . The distribution of the number of complications and LOS is shown in Figures 1 and 2. There was a significant difference between the three groups in LOS (p < 0.001, Figure 1) and number of complications ( p = 0.012, Figure 2). The median LOS was highest in the indeterminant group (4 days) and lowest in the antibiotic group (2 days[VV2] ). The development of abscess was 32.4% of patients treated with antibiotics only, 11.4% of patients treated with appendectomy and 26.4% of patients in the indeterminant treatment group.
Conclusion: Despite several RCT’s demonstrating the efficacy of an antibiotic-first strategy, the overwhelming majority of acute appendicitis patients are treatment with appendectomy in Florida. While the initial treatments of appendectomy and antibiotics had similar rates of complications, there was a much higher frequency of abscess development in patients the antibiotic-first form group. The findings support that antibiotic-only treatment for uncomplicated appendicitis may show less effectiveness compared to appendectomy in clinical practice
