A1 Refereed original research article in a scientific journal
Prognostic factors associated with primary non-responsiveness to antibiotics and appendicitis recurrence for CT-diagnosed uncomplicated acute appendicitis: secondary analysis of two randomized clinical trials
Authors: Selänne, Liisa; Hurme, Saija; Sippola, Suvi; Rautio, Tero; Nordström, Pia; Rantanen, Tuomo; Pinta, Tarja; Ilves, Imre; Mattila, Anne; Savela, Eeva-Liisa; Rintala, Jukka; Paajanen, Hannu; Grönroos, Juha; Haijanen, Jussi; Salminen, Paulina
Publisher: Oxford University Press (OUP)
Publishing place: OXFORD
Publication year: 2025
Journal: British Journal of Surgery
Journal name in source: British Journal of Surgery
Journal acronym: BJS-BRIT J SURG
Article number: znaf143
Volume: 112
Issue: 7
Number of pages: 9
ISSN: 0007-1323
eISSN: 1365-2168
DOI: https://doi.org/10.1093/bjs/znaf143
Web address : https://doi.org/10.1093/bjs/znaf143
Self-archived copy’s web address: https://research.utu.fi/converis/portal/detail/Publication/499690185
Background: Antibiotics are safe and efficient for CT-diagnosed uncomplicated acute appendicitis. Identifying predictive factors of primary non-responsiveness or recurrence would further improve antibiotic treatment success and safety.
Methods: All patients treated with antibiotics in two large RCTs (APPAC and APPAC II) were included. The primary non-responsiveness analysis compared patients operated on within 30 days after randomization for complicated appendicitis with either patients presenting with uncomplicated appendicitis at surgery within 30 days or patients with successful antibiotic treatment during 3-year follow-up. Prognostic factors for appendicitis recurrence were assessed by comparing patients with successful antibiotic treatment with patients with acute appendicitis operated on after 30 days of initial antibiotics.
Results: Of 856 patients randomized to antibiotics (mean(s.d.) age of 36(12) years; 365 (42.6%) were women), 832 were eligible for non-responsiveness analysis and 732 for appendicitis recurrence analysis. Findings associated with primary non-responsiveness on admission included an appendiceal diameter ≥15 mm (adjusted risk ratio (RR) 4.00 (95% c.i. 2.00 to 7.92) (P < 0.001)) and a body temperature >38°C (adjusted RR 2.76 (95% c.i. 1.27 to 6.03) (P = 0.011)). During the first 6-30 h after admission, C-reactive protein (CRP) ≥100 mg/l (negative predictive value of 99%) and leucocyte count ≥9 × 109/l were associated with primary non-responsiveness (adjusted RR 8.29 (95% c.i. 3.69 to 18.63) (P < 0.001) and adjusted RR 4.44 (95% c.i. 1.79 to 11.05) (P = 0.001) respectively). No prognostic findings for appendicitis recurrence were identified.
Conclusion: Patients with an appendiceal diameter ≥15 mm and a body temperature >38°C may not be optimal candidates for non-operative treatment for uncomplicated acute appendicitis. Patients with CRP <100 mg/l at 24 h of antibiotic treatment for uncomplicated acute appendicitis have a 99% likelihood of successful antibiotic therapy.
Registration numbers: NCT03236961 and NCT01022567 (http://www.clinicaltrials.gov).
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Funding information in the publication:
The study was supported by research grants from the Mary and Georg C. Ehrnrooth Foundation (P.S. and J.H.), the Sigrid Juselius Foundation (P.S.), the Finnish Academy (P.S.), the Orion Research Foundation (J.H and L.S.), the Gastroenterological Research Foundation (J.H.), and the Finnish Medical Foundation (J.H and L.S.), and a government research grant (EVO Foundation) awarded to Turku University Hospital (P.S., J.H and L.S.), and the Turku University Foundation (L.S.). None of the funding entities had a role in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.
