The APPAC trial (Finland) randomized adults with uncomplicated acute appendicitis (CT-confirmed) to appendicectomy versus antibiotic therapy (IV ertapenem then oral levofloxacin/metronidazole for 7 days). What was the primary outcome at 5-year follow-up?

• A Antibiotic therapy was non-inferior to surgery with >90% success in avoiding appendicectomy at 5 years
• B Antibiotic therapy had a significantly higher perforation rate than surgery group
• C All patients treated with antibiotics eventually required appendicectomy within 10 years
• D Approximately 39-40% of patients initially treated with antibiotics required appendicectomy within 5 years; however, no antibiotic-treated patient developed complications from delayed appendicectomy ✓

Explanation

The APPAC trial's 5-year follow-up (Salminen et al., JAMA 2018) showed that 39.1% of patients in the antibiotic arm required appendicectomy within 5 years (most within the first year). Importantly, no patient who required delayed appendicectomy had a perforated or gangrenous appendix at the delayed operation, suggesting that monitoring and delayed surgery did not compromise safety. The 5-year success rate of antibiotic therapy in avoiding appendicectomy was 60.2%. Non-inferiority criteria were not met due to the high failure rate, but antibiotics remain an option for selected patients who wish to avoid surgery, provided they understand the 39% risk of eventual appendicectomy.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.