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Monsell SE, Voldal EC, Davidson GH, Fischkoff K, Coleman N, Bizzell B, Price T, Narayan M, Siparsky N, Thompson CM, Ayoung-Chee P, Odom SR, Sanchez S, Drake FT, Johnson J, Cuschieri J, Evans HL, Liang MK, McGrane K, Hatch Q, Victory J, Wisler J, Salzberg M, Ferrigno L, Kaji A, DeUgarte DA, Gibbons MM, Alam HB, Scott J, Kao LS, Self WH, Winchell RJ, Villegas CM, Talan DA, Kessler LG, Lavallee DC, Krishnadasan A, Lawrence SO, Comstock B, Fannon E, Flum DR, Heagerty PJ. Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis. JAMA Surg 2022; 157:e216900. [PMID: 35019975 PMCID: PMC8756360 DOI: 10.1001/jamasurg.2021.6900] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE 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. OBJECTIVE 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. EXPOSURES Appendectomy vs antibiotics. MAIN OUTCOMES AND MEASURES 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. RESULTS 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). CONCLUSIONS AND RELEVANCE 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.
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Affiliation(s)
| | | | | | | | | | | | | | - Thea Price
- Rush University Medical Center, Chicago, Illinois
| | | | | | - Callie M Thompson
- Vanderbilt University Medical Center, Nashville, Tennessee.,University of Utah, Salt Lake City
| | - Patricia Ayoung-Chee
- Tisch Hospital NYU Langone Medical Center, New York, New York.,Morehouse School of Medicine, Atlanta, Georgia
| | - Stephen R Odom
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Joseph Cuschieri
- Harborview Medical Center, UW Medicine, Seattle, Washington.,University of California, San Francisco
| | - Heather L Evans
- Harborview Medical Center, UW Medicine, Seattle, Washington.,University of South Carolina, Charleston
| | - Mike K Liang
- Lyndon B. Johnson General Hospital, University of Texas, Houston.,University of Houston, HCA Healthcare, Kingwood, Texas
| | | | | | - Jesse Victory
- Bellevue Hospital Center, NYU School of Medicine, New York, New York
| | - Jon Wisler
- Ohio State University Medical Center, Columbus
| | | | | | - Amy Kaji
- Harbor-UCLA Medical Center, West Carson, California
| | | | | | - Hasan B Alam
- University of Michigan Medical Center, Ann Arbor.,Northwestern University, Evanston, Illinois
| | - John Scott
- University of Michigan Medical Center, Ann Arbor
| | - Lillian S Kao
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | - Wesley H Self
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - David A Talan
- Olive View-UCLA Medical Center, Los Angeles, California.,Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | - Danielle C Lavallee
- University of Washington, Seattle.,BC Academic Health Science Network, Vancouver, Canada
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