CODA RCT – Antibiotics or Surgery for Appendicitis?

November 17, 2020

Written by Clay Smith

Spoon Feed
Antibiotic treatment vs appendectomy for appendicitis had non-inferior 30-day quality of life scores, but need for subsequent surgery and complications were greater in the antibiotic group, especially in patients with an appendicolith.

Why does this matter?
Several studies have suggested antibiotic therapy for appendicitis is a viable option. I have had my doubts. A surgery journal found operative treatment was better. A pediatric journal found non-operative treatment was an option. The CODA collaborative thought there was clinical equipoise and did this RCT.

CODA – the ending is not what we want
This was a non-blinded, non-inferiority, multicenter randomized trial of 1,552 adults with image-confirmed appendicitis. There was non-inferiority for the primary outcome of quality of life score at 30 days. Scores were nearly identical. However, in patients treated with antibiotics, 29% had undergone appendectomy by 90 days (including 25% of those who did not have an appendicolith). Complications, such as infection, need for a drain, or antibiotic-related reactions were more common in the antibiotic group, mainly driven by the subgroup of patients with an appendicolith. That’s not good. This meant more repeat ED visits, more CT scans, more time, and possibly more money. In other words, too many patients in the antibiotic group had a dissonant coda.

Source
A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Oct 5. doi: 10.1056/NEJMoa2014320. Online ahead of print.

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Another Spoonful
See this note from the lead author for a balanced and pragmatic take on this study.