NEJM Journal Watch
Thomas L. Schwenk, MD, reviewing
The presence of an appendicolith doubled the likelihood of subsequent appendectomy.
In a recent study, appendiceal diameter of ≥15 mm or fever >38°C predicted early failure of antibiotic therapy for uncomplicated appendicitis (NEJM JW Gen Med Feb 1 2022 and JAMA Surg 2021; 156:1179) Now, investigators have explored the same question in a secondary analysis of data from a previous randomized antibiotics-versus-surgery trial (NEJM JW Gen Med Dec 1 2020 and N Engl J Med 2020; 383:1907). They identified 735 patients who had been randomized to antibiotic treatment; 154 (21%) of these patients underwent appendectomy within 30 days.
In adjusted analyses, the strongest association with 30-day appendectomy was presence of an appendicolith (i.e., inspissated and mineralized stool; odds ratio, 1.99). Smaller and barely significant associations were found with female sex (OR, 1.53) and large appendiceal diameter (OR per 1-mm increase, 1.09). No association was noted with age, comorbidities, or typical measures of appendicitis severity.
These data might help primary care clinicians with patients who seek guidance about possible use of antibiotics in appendicitis. However, editorialists note that in subsequent analyses of this same data set, nearly 50% of patients underwent appendectomy within 2 years, regardless of the presence of an appendicolith, so an initial nonsurgical approach might only delay surgery. They also noted that all the excess risk associated with appendicolith occurs in the first 48 hours — from then on, its presence does not have predictive value. All in all, some patients might avoid surgery for appendicitis, but antibiotics will have only temporizing value for many.
Leave a Reply
You must be logged in to post a comment.