University of Washington, Seattle.
Columbia University Medical Center, New York, New York.
JAMA Surg. 2022 Mar 1;157(3):e216900. doi: 10.1001/jamasurg.2021.6900. Epub 2022 Mar 9.
Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days. Identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics could support more individualized decision-making.
To assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis.
DESIGN, SETTING, AND PARTICIPANTS: In this cohort study using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial, characteristics among patients who initiated antibiotics were compared between those who did and did not undergo appendectomy within 30 days. The study was conducted at 25 US medical centers; participants were enrolled between May 3, 2016, and February 5, 2020. A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Data were analyzed from September 2020 to July 2021.
Appendectomy vs antibiotics.
Conditional logistic regression models were fit to estimate associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for nonclinical reasons.
Of 776 participants initiating antibiotics (mean [SD] age, 38.3 [13.4] years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days. After adjustment for other factors, female sex (odds ratio [OR], 1.53; 95% CI, 1.01-2.31), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09; 95% CI, 1.00-1.18), and presence of appendicolith (OR, 1.99; 95% CI, 1.28-3.10) were associated with increased odds of undergoing appendectomy within 30 days. Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28; 95% CI, 0.82-1.98) were not associated with odds of 30-day appendectomy. The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41; 95% CI, 1.49-3.91).
This cohort study found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis were not associated with odds of 30-day appendectomy. This information may help guide more individualized decision-making for people with appendicitis.
基于 30 天的自我报告健康状况，使用抗生素治疗阑尾炎是安全的，且与阑尾切除术非劣效。确定在开始使用抗生素的 30 天内更有可能进行阑尾切除术的患者特征，这可以支持更个体化的决策。
评估与在开始使用抗生素治疗阑尾炎的 30 天内进行阑尾切除术相关的患者因素。
设计、地点和参与者：在这项使用来自抗生素药物与阑尾切除术比较（CODA）随机临床试验数据的队列研究中，比较了在开始使用抗生素的患者中，那些在 30 天内进行和未进行阑尾切除术的患者之间的特征。该研究在 25 家美国医疗中心进行；参与者于 2016 年 5 月 3 日至 2020 年 2 月 5 日期间入组。共有 1552 名急性阑尾炎患者被随机分配至抗生素组（776 名参与者）或阑尾切除术组（776 名参与者）。数据于 2020 年 9 月至 2021 年 7 月进行分析。
阑尾切除术与抗生素。
使用条件逻辑回归模型来估计特定患者因素与开始使用抗生素后 30 天内进行阑尾切除术的几率之间的关联。进行了一项敏感性分析，排除了 30 天内因非临床原因进行阑尾切除术的参与者。
在 776 名开始使用抗生素的参与者中（平均[SD]年龄为 38.3[13.4]岁；286[37%]名女性和 490[63%]名男性），735 名参与者有 30 天的结局，包括 154 名（21%）在 30 天内行阑尾切除术的参与者。在调整其他因素后，女性（比值比[OR]，1.53；95%CI，1.01-2.31）、阑尾直径较宽的影像学表现（每增加 1mm 的 OR 为 1.09；95%CI，1.00-1.18）和存在阑尾结石（OR，1.99；95%CI，1.28-3.10）与 30 天内行阑尾切除术的几率增加相关。与并发症风险增加相关的特征（例如，年龄较大、合并症）以及临床医生经常用来描述阑尾炎严重程度的特征（例如，发热：OR，1.28；95%CI，0.82-1.98）与 30 天内阑尾切除术的几率无关。限于因临床原因而行阑尾切除术的敏感性分析提供了关于阑尾结石的类似结果（调整后的 OR，2.41；95%CI，1.49-3.91）。
这项队列研究发现，存在阑尾结石与在开始使用抗生素后 30 天内行阑尾切除术的风险增加近 2 倍相关。常用于描述阑尾炎严重程度的临床特征与 30 天内阑尾切除术的几率无关。这些信息可能有助于为阑尾炎患者提供更个体化的决策。
