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Antibiotics vs Surgery for Acute Appendicitis: Toward a Patient-Centered Treatment Approach.

The publication of the Appendicitis Acuta (APPAC) trial in JAMA by Salminen et al1 generated significant debate about the best way to treat this common disease. This high profile study challenged more than 100 years of practice, attracted extensive media coverage, and sparked animated debate among physicians about the safety and efficacy of antibiotics therapy for treatment of uncomplicated appendicitis. This Viewpoint reviews the study results, outlines both sides of an ongoing debate, and provides recommendations for surgeons who will be confronted by patients questioning whether they need surgery. The APPAC Trial is the largest multicenter randomized clinical trial comparing antibiotic therapy with appendectomy for the treatment of acute appendicitis.1 The authors found that among patients with computed tomography–confirmed uncomplicated appendicitis who were treated with antibiotics, 73% did not require appendectomy within 1 year of initial presentation, while 27% did. Among those who subsequently underwent surgery following antibiotics failure, the complication rate was no higher than for patients who received appendectomy initially, and no patients developed intraabdominal abscess. This result demonstrated that antibiotic treatment is not detrimental in the long term to patients for whom it fails. Perhaps the most striking result of the APPAC Trial was the variability in how the findings were interpreted. Two distinct waves of reaction drew nearly opposite conclusions from the same data. First, the study generated extensive media coverage. NBC’s Nightly News, the Today show, the New York Times, and Time magazine all reported that antibiotics are a potentially viable treatment option. Time reported that antibiotics are now a “strong alternative” to surgery.2 The New York Times’ headline read: “Antibiotics Are Effective in Appendicitis, Study Says,” and strongly questioned the need for surgery, stating “most patients can be treated with antibiotics alone.”3 The second wave of reaction came from surgeons, who interpreted the same data in nearly the opposite way. Surgeons were highly resistant to the idea of antibiotic treatment, with many crying foul over the study methodology and the media’s portrayal of the results. A robust debate over the validity of the study erupted on Twitter, prompting the Behind the Knife podcast to broadcast a debate among surgeons.4 Many surgeons viewed the reported failure rate of 27% as a major problem, proving that antibiotics were not a viable alternative to appendectomy. Most critical was the aptly named Skeptical Scalpel blog,5 which outlined multiple methodological concerns with the study. The blog’s author pointed out that 95% of operations were performed open, which increased complication rates and length of stay relative to the laparoscopic approach (by far the leading approach in the United States). Additionally, the antibiotics arm received ertapenem, which required a 3-day hospital stay for administration and is not considered a first-line antibiotic in much of the world. Finally, the blog post contended that the study did not consider recurrent appendicitis as a complication of antibiotic treatment, thus underreporting the true rate of complication and that 1 year of follow-up was insufficient to capture all recurrences of appendicitis. However, amid the sea of articles, tweets, and blog posts over the “right” treatment, the debate has lost consideration for its ultimate stakeholder—the patient. Given the extensive media coverage, patients are increasingly likely to be aware of antibiotics as a treatment approach and ready to suggest it to their surgeons. From the patient’s perspective, this study has turned a clinical situation that mandated an operation into one with trade-offs: an immediate surgery with a 100% cure rate vs avoiding surgery upfront with a 27% failure rate. Neither of these options is right. And neither is wrong. To patients, this will become a classic exercise in balancing the pros and cons of 2 treatment alternatives. The right treatment option hinges on how the patient individually values the trade-offs. Rather than a surgeon-centric debate about whether antibiotics are “valid,” the discussion we need to have is about how surgeons can best engage in shared decision making with patients on treatment options for appendicitis. Shared medical decision making is the process by which physicians and patients reach a mutually agreeable decision for treatment by considering patient values and preferences along with the specific risks and benefits of treatment options. Through shared decision making we can answer the question that we should be asking: which is the right option for this patient? When considering the patient in shared decision making, the most important question is: what are their goals for treatment? Some patients may place a high value on the certainty provided by immediate surgery. Undergoing emergent surgery at presentation will result in a 1-day hospital stay (with laparoscopic appendectomy) and virtually no chance that they will have to deal with appendicitis again.6 The patient requesting immediate operation requires little discussion. Alternatively, some patients may place a very high value on delaying surgery or avoiding it at any cost. To these patients, a 3-day hospital stay (the current protocol for intravenous antibiotic treatment) and either interval appendectomy or a 27% chance of unplanned surgery down the road may be judged a small price to pay for avoiding surgery now. Understanding why a patient is lookVIEWPOINT