A randomized trial comparing antibiotics with appendectomy for appendicitis

David R. Flum*, Giana H. Davidson, Sarah E. Monsell, Nathan I. Shapiro, Stephen R. Odom, Sabrina E. Sanchez, F. Thurston Drake, Katherine Fischkoff, Jeffrey Johnson, Joe H. Patton, Heather Evans, Joseph Cuschieri, Amber K. Sabbatini, Brett A. Faine, Dionne A. Skeete, Mike K. Liang, Vance Sohn, Karen McGrane, Matthew E. Kutcher, Bruce ChungDamien W. Carter, Patricia Ayoung-Chee, William Chiang, Amy Rushing, Steven Steinberg, Careen S. Foster, Shaina M. Schaetzel, Thea P. Price, Katherine A. Mandell, Lisa Ferrigno, Matthew Salzberg, Daniel A. DeUgarte, Amy H. Kaji, Gregory J. Moran, Darin Saltzman, Hasan B. Alam, Pauline K. Park, Lillian S. Kao, Callie M. Thompson, Wesley H. Self, Julianna T. Yu, Abigail Wiebusch, Robert J. Winchell, Sunday Clark, Anusha Krishnadasan, Erin Fannon, Danielle C. Lavallee, Bryan A. Comstock, Bonnie Bizzell, Patrick J. Heagerty, Larry G. Kessler, David A. Talan

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

289 Scopus citations


BACKGROUND Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life–5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], −0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith.

Original languageEnglish
Pages (from-to)1907-1919
Number of pages13
JournalNew England Journal of Medicine
Issue number20
StatePublished - 12 Nov 2020
Externally publishedYes


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