VIEWPOINT

 

South Africa needs to reject the concept of antibiotics as the primary treatment of acute uncomplicated appendicitis

 

 

VY Kong^{I, II}; DL Clarke^{II, III}

^IDepartment of Surgery, University of Auckland, New Zealand
^IIDepartment of Surgery, University of KwaZulu-Natal, South Africa
^IIIDepartment of Surgery, University of the Witwatersrand, South Africa

Correspondence

 

 

The movement in the high-income countries of the world away from surgery as the mainstay of treatment for acute uncomplicated appendicitis, has been well documented and is supported both in the literature and by several prominent surgical societies, in both North America and Europe.^1,2 The proponents of this approach point to the cost savings associated with reduced use of operating theatres and laparoscopic equipment, as well as the prevention of long-term morbidity such as port site hernias and abdominal adhesions.^1,2 They also point to the use of antibiotics as first-line therapy in other abdominal emergencies such as acute diverticulitis. In acute diverticulitis antibiotic therapy may abort acute low-grade inflammation and help avoid surgery, which traditionally involves a morbid stoma. The proponents of non-operative management of acute uncomplicated appendicitis point to the many benefits of this approach. The recent Comparison of Antibiotic Drugs and Appendectomy (CODA) trial which randomised 1 552 adult patients with acute uncomplicated appendicitis, to either laparoscopic appendicectomy or antibiotic therapy, concluded that antibiotics were non-inferior to appendectomy based on results of a standard health-status measure. It should be noted that in the antibiotics group, nearly 3 out of every 10 participants had subsequently undergone an appendectomy by 90 days. Also of note is that patients with an appendicolith were at a higher risk for delayed appendectomy and complications than those without an appendicolith.^1,2 The authors went on to state that in the antibiotics group, more than 7 in 10 participants avoided surgery, were treated mostly as outpatients and subsequently missed fewer days at work.

Whilst it seems, superficially, to make sense to want to reduce the need for and incidence of an operative procedure, the South African context must be taken into account. We have written extensively about the outcome of acute appendicitis in rural South Africa. The disease South African surgeons confront bears scant similarity to that managed by the authors of the CODA study.^1,2 Essentially acute appendicitis in the developing world represents massive "health systems failure" with delayed recognition and delayed definitive treatment being the norm.^3-6 This translates into high rates of open surgery with significant morbidity and even mortality. Rural patients remote from regional and tertiary hospitals have a worse disease profile and worse outcomes.^3-6 The issue is one of recognition of disease rather than of treatment protocols. Despite efforts to improve surgical care in the rural hinterland of the country, surgical capacity at district hospitals seems to have deteriorated rather than improved over the last three decades. There is little sign of this situation changing.^7,8 Even laparoscopic approaches to acute appendicitis are limited by the advanced stage of disease confronted in the state sector institutions.

The situation in private practice is different in terms of the stage of disease seen.^9,10 However, the issue in private practice is the nature of the system of care. Busy sole surgical practitioners, without the support of house staff and trainees to help review and regularly reassess patients, are more likely to opt for a definitive low risk surgical solution, than an approach that requires repeated observation and reassessment. It is difficult to convince patients that a prolonged course of antibiotics, entailing fairly strict follow-up, is a better option than a relatively short and uncomplicated definitive operation. The fact that thirty per cent of patients go on to need an appendicectomy at some point in the future, suggests that antibiotic therapy is simply delaying the inevitable.^1,2 Unlike the situation in acute diverticulitis, where the acute surgery frequently involves a stoma and may involve repeat surgery, laparoscopic appendicectomy is relatively safe and well tolerated. We are not comparing like with like, by pointing to acute diverticulitis and that argument is a non sequitur.

There are other concerns with a non-operative approach. These include the spectre of delayed recognition of an appendicular malignant lesion with an observation and antibiotic only strategy. The suggestion that patients who successfully complete non-operative therapy for acute appendicitis should undergo delayed or interval appendicectomy is difficult to appreciate. It seems as if the proponents of such a strategy are trying to have their cake and eat it too. It is difficult to see any advantage in delaying an appendicectomy for a few weeks or months. As such, we find that we cannot support the suggestion that antibiotic therapy for acute uncomplicated appendicitis be rolled out in the South African context.

ORCID

VY Kong https://orcid.org/0000-0003-2291-2572

DL Clarke https://orcid.org/0000-0002-8467-1455

 

REFERENCES

1. CODA Collaborative. A randomised trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020;383(20):1907-19. https://doi.org/10.1056/NEJMoa2014320.         [ Links ]

2. De Almeida Leite RM, Seo DJ, Gomez-Eslava B, et al. Nonoperative vs operative management of uncomplicated acute appendicitis: a systematic review and meta-analysis. JAMA Surg. 2022;157(9):828-34. https://doi.org/10.1001/jamasurg.2022.2937.         [ Links ]

3. Yang E, Kahn D, Cook C. Acute appendicitis in South Africa: a systematic review. S Afr J Surg. 2015;53(3 and 4):31-8.         [ Links ]

4. Kong VY, Bulajic B, Allorto NL, et al. Acute appendicitis in a developing country. World J Surg. 2012;36(9):2068-73. https://doi.org/10.1007/s00268-012-1626-9.         [ Links ]

5. Kong VY, Sartorius B, Clarke DL. Acute appendicitis in the developing world is a morbid disease: a clinical review of 1004 cases in a university hospital in South Africa. Ann R Coll Surg Engl. 2015;97(5):390-5. https://doi.org/10.1308/003588415X14181254790608.         [ Links ]

6. Kong VY, Aldous C, Handley J, Clarke DL. The cost effectiveness of early management of acute appendicitis underlies the importance of curative surgical services to a primary healthcare programme. Ann R Coll Surg Engl. 2013; 95(4):280-4. https://doi.org/10.1308/003588413X13511609958415.         [ Links ]

7. Tefera A, Lutge E, Clarke DL. Bellwether operations in KwaZulu-Natal Province, South Africa, are performed at regional and tertiary rather than district hospitals. S Afr Med J. 2020;110(5):374-6. https://doi.org/10.7196/SAMJ.2020.v110i5.14218.         [ Links ]

8. Tefera A, Lutge E, Sartorius B, et al. The operative output of district hospitals in KwaZulu-Natal Province is heavily skewed toward obstetrical care. World J Surg. 2019 ;43(7):1653-60. https://doi.org/10.1007/s00268-019-04985-1.         [ Links ]

9. Yang E, Cook C, Kahn D. Acute appendicitis in the public and private sectors in Cape Town, South Africa. World J Surg. 2015;39(7):1700-7. https://doi.org/10.1007/s00268-015-3002-z.         [ Links ]

10. Mills RP, Clarke DL, Kong VY. Appendicectomy in private practice in KwaZulu-Natal Province, South Africa. S Afr Med J. 2018;108(10):836-8. https://doi.org/10.7196/SAMJ.2018.v108i10.13151.         [ Links ]

 

 

Correspondence:
email: victorywkong@yahoo.com