Efficacy and cost-utility of antibiotic uses and surgical treatments in uncomplicated acute appendicitis

Abstract

Appendicitis is the most common abdominal urgent condition in general surgical practice. Although appendectomy was a gold standard treatment management, its procedure was associated with post-operative complications and new instruments and technologies have been launched over times. Recently, conservative treatments with antibiotics have been studied and considered as an alternative choice for uncomplicated appendicitis and individual antibiotics might have more cost-utility than appendectomy either laparoscopic appendectomy (LA) or open appendectomy (OA). Therefore, this study was conducted to provide evidence and information aiding decision making to prescribe antibiotic treatment or surgical treatment for uncomplicated acute appendicitis. Objectives: 1) To assess and compare rates of success and overall major complications between LA and OA, 2) To estimate health-related quality of life (HRQoL) among antibiotic treatment and surgical treatment within one year due to the intervention, and 3) To perform cost-utility to estimate incremental cost-effectiveness ratio (ICER) among individual antibiotics, LA and in uncomplicated acute appendicitis. Methods: For the first objective, an umbrella review of meta-analyses (MAs) was performed with update MAs to assess and compare rates of success and overall major complications between LA and OA. MAs were identified from PubMed and Scopus databases published from Jan 1990 to July, 2018. The fixed or random effect model was applied to the pool treatment effects. For the second objective, a cohort study was conducted to estimate HRQoL among the antibiotic treatment and operative treatment at Ramathibodi Hospital. The EQ5D-5L was applied to HRQoL, For last objective, the cohort study was applied to collect the direct non-medical cost, and indirect cost and a retrospective study was applied for direct cost from November 2018 to October 2019. To perform cost-utility by an ICER among the individual antibiotics and surgical treatment in uncomplicated acute appendicitis, the Tornado diagram was plotted to report which of one-way sensitivity analyses should be applied. Results: Ten MAs were eligible; surgical site infection (SSI) was reported in all MAs and intra-abdominal abscess (IAA) in 8 MAs. SSI rate was 48% to 70% lower in LA than OA, but conversely IAA rate was 1.34 to 2.20 higher in LA than OA. The risk ratios (RRs) (95% CI) comparing LA vs OA were re-pooled in adults and children yielding RRs of 0.56 (0.47, 0.67) and 0.40 (0.25, 0.65) for SSI; and 1.20 (0.88, 1.63) and 1.05 (0.61, 1.80) for IAA. After estimated by treatment model the results showed antibiotics treatments were higher than surgical treatment especially in beta-lactamase with 0.97 (0.94, 0.99) which was significantly higher difference compared with OA. CUA was performed to estimate ICER among individual antibiotics (beta-lactamase, quinolone, and 3rd generation of cephalosporin+metronidazole), LA, and OA in uncomplicated acute appendicitis. This aimed to compare antibiotics treatment and surgical treatment and indicated an ICER -304,229.79 Baht per utility gained. Conclusion: The antibiotics treatment suggested more utility score with the trend to use the lower cost of treatment rather than the surgical treatment in the uncomplicated acute appendicitis patients. Therefore, the antibiotics treatment should be considered for the alternative choice for the patients to decrease the complication rate from the surgical treatment.