2-day antibiotic non-inferior to 5-day antibiotic therapy for postoperative management of complex appendectomy

1. The rate of infectious complications and mortality at 90 days was similar between groups.

2. No treatment-related deaths were reported and fewer patients in the 2-day antibiotic group reported adverse events than in the 5-day group.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Intravenous antibiotics following complex appendectomy is the current standard of practice. However, the appropriate duration of antibiotic therapy remains unclear as recent studies have suggested a shorter course of antibiotics may be sufficient while also reducing the duration of hospital stay and prolonged antibiotic use. This randomized controlled trial aimed to compare the safety and efficacy of 2-day versus 5-day intravenous antibiotics among patients who underwent laparoscopic appendectomy for complicated appendicitis. The primary outcome was infectious complications and mortality within 90 days following surgery while key secondary outcomes included duration of postoperative antibiotics, rates of intra-abdominal abscess, and surgical-site infection. According to study results, in both groups, the rate of 90-day infectious complications and mortality were similar in both groups with the 2-day group satisfying the noninferiority criteria. Although there was a shorter median hospital admission in the 2-day group, the rates of re-admission were significantly increased in the 2-day group compared to the longer duration of therapy. However, the follow-up after hospital discharge was approximately sixty-six percent and patients were not standardized to oral antibiotic therapy after discharge due to medication adherence concerns.

Click to read the study in The Lancet

Relevant Reading: A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

In-depth [randomized-controlled trial]: Between April 12, 2017, and June 3, 2021, 13 267 patients were assessed for eligibility from 15 hospitals in the Netherlands. Included were patients ≥ 8 years of age with complex appendicitis (either necrosis, perforation, or abscess) and an American Society of Anesthesiologists classification of I-III. Altogether, 1066 patients (533 in the 2-day course and 533 in the 5-day course) were included in the primary analysis. The primary outcome of infectious complications and mortality within 90 days occurred in 10% of patients in the 2-day group and 8% of patients in the 5-day group (absolute risk difference 2.0%, 95% confidence interval [CI] -1.6 to 5.6). Although re-admission to the hospital was more common in the 2-day group than in the 5-day group (12% vs. 6%, odds ratio [OR] 2.135, 95% CI 1.342-3.396), there were fewer patients with adverse effects of antibiotics in the 2-day group (9% vs. 22%, OR 0.344, 95% CI 0.237-0.498). Overall, findings from this study suggest non-inferiority between 2-day and 5-day courses of intravenous antibiotics following laparoscopic appendectomy.

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