Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study
Authors: Javanmard-Emamghissi H , Hollyman M , Boyd-Carson H , Doleman B , Adiamah A , Lund J N , Moler-Zapata S , Grieve R , Moug S J , Tierney G M ,   The COVID: HAREM (Had Appendicitis and Resolved/Recurred Emergency Morbidity/Mortality) Collaborative Group, Kulkarni N , Pereira I , Barlow S , Vanniasegaram S , Loro F , Blencowe N S , Zucker B E , Tyler A , Hollyman M , Kosti A , Wijeyaratne M , Badenoch T , Wheatstone S , Jaffer M , Gerretsen H , Sajid M S , Kennedy L , Malik A , Nada A , Ray K , Khan M , Varcada M , Froghi F , Khalil A , Kyprianou D , Tewari N , Sarma D R , Baig M , Sood S , Yu Wen Ng E , Ng V , Shortland T , Marangoni G , Khan S , Ahmad J , Brown S , Steele C , Pannu A , Gemmill E , Boyd-Carson H , Herrod P , Singh Shari S , Mohammed M J S , Narbad V , Hanbali N , Kushairi A , Mathew M A , Downey C , Alamassi A , Wheatley T , Emslie K , Alcocer B , Lau S , Morgan R , Gala T , Ibrahim S , Stephanos M , Mithany R , Abdelkarim M , Venkatesan G , Aqsalan A , Taylor J , Fok M , Kattakayam A , Rajput K , Bevan K , Kim H-K , Salih L , Sabaratnam R , Creanga M , Shafi A , Law J , Elniel M , Walley M , Ayyar S , Cornish J , Reeves N , Mowbray N , Mayo I , Chohda E , McCaughran W , Beck E , Garikipati S , Lovett B E , Alkistawi F , Franklin S , Hadjitoffi C , Uddin A , Patel P K , Handa S , Parker J , Littlehales D , Belgaumkar A P , Oyewole B , Narayan P , Elahi Z , Gaukroger A , Dunne D F J , Nita G E , Baron R D , Sochorova D , Szatmary P , Gahunia S A K , Thomas A J , Mann K S , McFall M , Farkas N , Siddig H , Camilleri-Brennan J , Rutherford D , Wilson M , Massie E , McGivern K , McGuckin J , McKee C , Marinos-Kouris S , Gammeri E , Patel N , Cillo G , Baldwin A J , Magro T , Krishna K , Olivier J , Anyaugo N , Philip K , Pearce L , Al-Amin A , Thomas M , Anderson I , Clark R , Basamh M , Navaratnam S M , Saunt A , Karki B Bekhyat , Jeong H , Singh B , Rajendirin A , Boyle K , Fahmy S , Couch J H , Butt H Z , Popa M , Sharma S , Cabdisalaam S , Kourdouli A , Zaheer M , Tierney G , Lund J N , Javanmard-Emamghissi H , Doleman B , Hope C , Gowda A , Photiou D , Malcolm F , Daliya P , Rye N , Chia Z , Anis F , Thomas P , Urbonas T , Centea D , Husain N , Moug S , Ingham A , Alexander R , Bisset C , Galbraith N , Clifford R , Dickerson L , Lockwood S , Johnston J , Guy R , Majeed T , Young R , Shamim S , Mesri M , Date R , Chaudhury M P , Zambas G , Patel R , Lewis S , Eigbadon A T , Thakrar D , Karamitsou E , Oyeyipo Y , Nadeem U , Ndlovu S , Fnshawe A , Henderson N , Payne C , Porter D , Brooks A , Lee R X N , Jackman J , Morton A J , Ebunoluwa Oyende O , Worku D , Koh A , Kanani T , Blackwell J , Shaw M , Lewis C Lloyd , Blackburn L , Adiamah A , Shaikh S , Ghazanfar M , Elhusseini M , Abdelhamid A , Eley J , Nassar A , Nunn R , Gales A , Farinella E , Mahmood Z , Policastro T , Bagnall N M , Blyth U , McGregor R J , Damaskos D , Drogouti M , Tuharska Z , Davies J , Bennett J M , Antakia R , O’Neill J R , Hardwick R H , Fearnhead N , Xanthis A , Georgiades F , Hudson V , Ashcroft J , Singh A A , Kabir S M U , Huan H , Sugrue M , Riera M , Chang J , Omosebi A , Rigby E , Kim L , Ali S , Gates Z , Alasa H , Bo J Y N , Gangwar A , Osborne L , Perakath B , Chandarana M , Galea M , Luhmann A , Ryska O , Searight F , McCoss C , Weber B , Sallam M , Patel R , Bignell M , Bond-Smith G , Lewis C , Williams G , Whewell H , Smith L , Ooi R , Powell-Chandler A , Tang A M , Richards S K , Thompson D B , Cross R , van Dellen J , Alberto V , Shirazi S , Arang H , Rahman N , Monaghan E , Dodds K , Babalola O , Airhunmwunde P , Chinaka C , Wijetunga I , Kidd T , Nambiar K , Ng C E , Collier T , Ibrahim B , Khan K , Sriskandarajah K , Pelly T , Vance-Daniel J , Nastro P , Khan A , Ekowo O , Devadoss A , Rao P D , Bateman K , Gavrila A , Hannan E , Winter D , Martin S , Kennelly R , Hanly A , Aslam M I , Amin V , Wilkins R , Zafar S , Konstantinou C , Mcdonald S , Baker A , Fardie A , Hill A , De Marchi J , O'Grady S , Faulkner G , Sekhar H , Martinez-Iglesias M , Alexander C , Lawrence E , Argyropoulos S , Williams G , Bhasin S , Paduraru M , Pawelec K , Bylapudi S , Byrne H , Da Silva Bento E R , Zahari F , Roslan F , Rao M , Hudson-Phillips S , Kenington C , Tellman S , Abraham P , Dhillon A , Vinnicombe Z , Giles M , Abbakar M , Khadem N , Buckley E , Macdonald L , Norman J , Bond R , White T , Gana T , Kotecha S , Rajain S , Ahmad S , Wadham B , Hancock L , Liyanage A , Dorrington I , Mian A , Satchidanand R Y , Weerasinghe C , Etherson K J , Hidayat H , Bhandari M , Agarwal A , Sagar J , Kudchadkar S , Ghosh A , Cirocchi N , Rai A , AlHabsha O , Mujtaba S S , Ejtehadi F , Warrag I , Ivanov B , Refson J , Boateng C , Madani R , Buhsk M M , Kesharwani D , Kumar L , Prakash V , Zulfiqar S , Jayakumar A , Payne A , Davies C , Buhain R , Osilli D , Rashid T , Elzayat I , Kanakala V , Nevins E J , Madhavan A , Oates E , France K , Cowie S , Bowen J , Nam Y-J , Bradbury M , Mitchell V , Mirza S M , Raiz M M , Weatherstone E , Wilson R , Sasapu K , Rahman M M A , Chan E , Ko K Y , Sharman M , Thiruppathy K , Hodgkinson J , Chadha R , Pilpel T , Dale J , Carter N , Botros A , Bondoqa I , Sandabah S , Sherwood K , Harries R , Hurt L , Egan R , Gauntlett L , Bevan V , Vipond M , Ireland P , Granger S , Preece R , Frith D , Eves J , Abuown A , Apollos J , Macleod A , Hemadasa N , McNaught C , Mir R , Cuthbert G , Valero C , Williams D , Fakhrul-Aldeen M , Willis K , Kelly L , Lawes D , Poynter L , Knowles H , Saeed S , Shehata M , Rafiq I , Boshnaq M , Ayoub F , Mcnair A , Pournaras D J , Lawday S , Martin R , Cohen H , Okocha M , Shalli K , Chin M , Joliffe S , Taylor F , Argyriou E O , Dornseifer M , Schembari E , Surandran S , Roberts L , Kakaniaris G , Mallidis E , Karagiannidis G , Youssef F , Chan A , Macutkiewicz C , Davenport M , Hodge S , Clarke A , Branagan G , Thakkar R , Harris C , Brown C , McGuigan M-C , Shrestha A K , Balakumar C , Iqbal S , Kawabata M , Ogbuagu N , Alam I , Wang K , Artemis F 
Published: July 2021

Abstract

Background
Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up.

Methods
A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment.

Results
A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P &lt; 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery.

Conclusion
This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.