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September 25, 2018

Antibiotic Treatment for Uncomplicated Appendicitis Really Works: Results From 5 Years of Observation in the APPAC Trial

JAMA. 2018;320(12):1245-1246. doi:10.1001/jama.2018.13368

Following publication of the Appendicitis Acuta (APPAC) trial in 2015,1 some were quick to criticize the report. APPAC compared outcomes for open appendectomy with antibiotic therapy for acute uncomplicated appendicitis, finding that antibiotics were a reasonable alternative to appendectomy. The study failed to meet its prespecified noninferiority margin to demonstrate that antibiotic treatment resulted in clinical outcomes that were “no worse than” outcomes with surgery, the operations were open and not laparoscopic, expensive broad-spectrum antibiotics were used, and the hospital lengths of stay were too long in each group (median, 3 days in the antibiotic group and in the surgery group). Despite the study limitations, of the 257 patients in the antibiotic group, 186 (73%) initially treated with antibiotics did not require surgery at the 1-year end point. However, concerns were raised that these patients would eventually require surgery, and various experts recommended that the APPAC results for clinical decision making not be used until the long-term outcomes were known for the patients who received antibiotic treatment. Wait, they advised.

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