Aaron J. Calderon, MD, FACP, SFHM reviewing
Moxifloxacin monotherapy and a multidrug intravenous-plus-oral regimen yielded similar success rates.
Based on evidence collected during the past decade, a 2020 international guideline (World J Emerg Surg 2020; 15:27) recommends discussing antibiotics as a safe alternative to surgery for managing uncomplicated acute appendicitis (defined as the absence of an appendicolith, perforation, or abscess). In previous studies, researchers evaluated intravenous (IV) antibiotics with transition to oral antibiotics. However, the effectiveness of a single oral antibiotic regimen has not been studied.
In this open-label trial, conducted in 9 Finnish hospitals, 600 adults (median age, 34) with uncomplicated acute appendicitis confirmed by computed tomography were randomized to oral moxifloxacin (400 mg daily) for 7 days or to IV ertapenem for 2 days followed by oral levofloxacin plus metronidazole for 5 days. Both therapies achieved the primary endpoint (i.e., ≥65% of patients discharged without surgery and no recurrence for ≥1 year); moxifloxacin had a 70% success rate, and ertapenem/levofloxacin had a 74% success rate. Median length of stay was about 1 day in both groups. However, moxifloxacin did not meet prespecified confidence limit criteria for “noninferiority.”
COMMENT
Even though the outcome with the all-oral regimen did not quite meet statistical criteria for noninferiority, the results support moxifloxacin monotherapy as a reasonable option for patients with uncomplicated appendicitis who hope to avoid surgery. It is also timely, as avoiding hospitalization during a pandemic might prevent exposure and preserve hospital resources. However, we must ensure that vulnerable patients, particularly uninsured patients, are not simply discharged home because an oral regimen exists. Patients who are treated with antibiotics should be advised that their probability of still requiring appendectomy during the ensuing year is roughly 30% (NEJM JW Gen Med Jul 15 2015 and JAMA 2015; 313:2340).