Duration of antibiotics in complicated appendicitis

We read with great interest the randomised study by Elisabeth M L de Wijkerslooth and colleagues,1de Wijkerslooth EML Boerma EG van Rossem CC et al.2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial.Lancet. 2023; 401: 366-376Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar who suggest that 2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days in terms of infectious complications and mortality within 90 days. This conclusion was based on a non-inferiority margin of 7·5%. Children participated in the trial, but patients who were pregnant or immunocompromised were excluded. Whether a 2-day course of antibiotics is safe in these patients remains unclear, which is a limitation of this study as described by the authors. The question of duration of therapy is more complicated than suggested by the authors’ summary. For example, the rate of postoperative infectious complications is higher in open appendicectomy than in laparoscopic surgery, including when converted from laparoscopic surgery, and standard practice is a full dose of antibiotics for 5 days.2de Wijkerslooth EML van den Boom AL Wijnhoven BPL Variation in classification and postoperative management of complex appendicitis: a European survey.World J Surg. 2019; 43: 439-446Crossref PubMed Scopus (13) Google Scholar, 3van den Boom AL de Wijkerslooth EML Mauff KAL et al.Interobserver variability in the classification of appendicitis during laparoscopy.Br J Surg. 2018; 105: 1014-1019Crossref PubMed Scopus (30) Google Scholar In de Wijkerslooth and colleagues’ study, the absolute risk difference also favoured 5 days of antibiotics for open procedure as in figure 2 of the Article,1de Wijkerslooth EML Boerma EG van Rossem CC et al.2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial.Lancet. 2023; 401: 366-376Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar suggesting that patients who required open surgery would most likely benefit from 5 days of antibiotics rather than 2 days. The authors indicated that a 5-day antibiotic regimen was the standard practice. Administration for 2 days possibly lowers the threshold for readmitting patients in the 2-day group, even though the infectious complications were reduced. Possibly, the decision to readmit should have been made by physicians blinded to the duration of therapy. Endoscopic retrograde appendicitis therapy (ERAT) is a new, feasible, and promising non-invasive treatment for acute appendicitis.4Yang B Kong L Ullah S et al.Endoscopic retrograde appendicitis therapy versus laparoscopic appendectomy for uncomplicated acute appendicitis.Endoscopy. 2022; 54: 747-754Crossref PubMed Scopus (15) Google Scholar ERAT can also be extended to perform appendicostomy with direct visualisation of the appendiceal mucosa. ERAT that is assisted with SpyGlass (Boston Scientific, Marlborough, MA, USA) is especially useful for acute appendicitis in pregnant women for whom surgical intervention or radiological examination might be deemed inappropriate or high risk.5Kong LJ Liu D Zhang JY et al.Digital single-operator cholangioscope for endoscopic retrograde appendicitis therapy.Endoscopy. 2022; 54: 396-400Crossref PubMed Scopus (15) Google Scholar Direct visualisation obviates the need for x-rays with or without contrast media, which is especially important in pregnant women. Patients with a perforated appendix, but who are not good candidates for surgery, might also benefit from ERAT-assisted drainage and management of perforation. Although concern surrounding appendiceal perforation appears justified, for the growing armamentarium of interventional endoscopists, particularly those with experience in performing natural orifice transluminal endoscopic surgery, the management of appendicoliths and its associated complications is becoming a feasible option. We declare no competing interests. Duration of antibiotics in complicated appendicitisWe read with interest the randomised controlled trial by Elisabeth M L de Wijkerslooth and colleagues1 revealing the preferable outcomes of short-term postoperative antibiotics (ie, 2 days) for complex appendicitis. However, we have concerns we wish to address. In the original manuscript, the authors noticed there were significantly higher hospital readmission rates (p=0·002) and shorter postoperative lengths of stay (3 days in the 2-day group vs 5 days in the 5-day group; p<0·0001) in the 2-day group in comparison with those in the 5-day group (as in table 3 of the appendix of the Article1). Full-Text PDF Duration of antibiotics in complicated appendicitis – Authors' replyWe thank the authors for their interest in our trial1 and their comments. Jiahao Meng and Shuguang Gao discuss the short-term complications in the 2-day antibiotics group. Similarly, Bing-Syuan Zeng and colleagues emphasise that the increased readmission rate in the 2-day group should not be overlooked. We agree that the increased readmission rate in the 2-day group calls for further analysis. Contrastingly, the readmissions did not necessarily represent severe adverse events. The decision to readmit a patient was made by the physician on call and was based on clinical judgement in our pragmatic trial. Full-Text PDF Duration of antibiotics in complicated appendicitisWe read with interest the trial by Elisabeth M L de Wijkerslooth and colleagues1 on 2 days versus 5 days of postoperative antibiotics for complex appendicitis. The authors found that 2 days of postoperative intravenous antibiotics is non-inferior to 5 days in terms of infectious complications and mortality within 90 days. Full-Text PDF Duration of antibiotics in complicated appendicitisElisabeth M L de Wijkerslooth and colleagues1 presented the findings from a multicentre, non-inferiority, randomised clinical trial designed to compare 2 days versus 5 days of antibiotics after appendicectomy in patients with complicated appendicitis. They showed that shorter duration is clinically non-inferior. We would like to congratulate the authors for this potentially practice-changing trial.1 We have a few comments regarding the study design and some of its conclusions. First, as well described in the literature, in patients who are clinically stable and non-toxic with perforated appendicitis or phlegmon, standard treatment includes antibiotics with percutaneous drainage of drainable abscesses given that immediate surgery in these patients is associated with higher complication rates. Full-Text PDF 2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days in terms of infectious complications and mortality within 90 days, based on a non-inferiority margin of 7·5%. These findings apply to laparoscopic appendicectomy conducted in a well resourced health-care setting. Adopting this strategy will reduce adverse effects of antibiotics and length of hospital stay. Full-Text PDF