Skipping Surgery?

36138532_thumbnailSurgery for acute appendicitis is a time-honored tradition, immortalized in the children's classic 'Madeleine.' Now, however, a study in JAMA and one Rick and I highlight this week on PodMed suggests that a course of antibiotics can help the majority avoid surgery altogether, and for the approximately one-quarter who will need to go to the OR, there is no significant consequence to waiting.  Wow.  Clearly a practice-changing finding if ever we've seen one.  In a study that could only be done outside our litigious culture, Finnish researchers randomized over 500 patients with acute, uncomplicated appendicitis confirmed by CT to either immediate surgery, or "intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day)."  The trial was designed to assess non inferiority of the antibiotic treatment, and just failed to meet that standard of 76% of patients avoiding surgery.  It did, however, have the outcomes I mentioned already.  Rick and I opine that if we presented with acute, uncomplicated appendicitis we would definitely opt for the trial of antibiotics, but concede that some folks might prefer an immediate solution via surgery.  Clearly the study informs shared decision-making between caregiver and patient but will likely take a lot of time to penetrate care patterns domestically.

Other topics this week include pregnancy and lupus, seat belts and motor vehicle fatalities,both in Annals of Internal Medicine,  and knee arthroscopy outcomes in the BMJ. Until next week, y'all live well.

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