• Suvi Sippola, Jussi Haijanen, Juha Grönroos, Tero Rautio, Pia Nordström, Tuomo Rantanen, Tarja Pinta, Imre Ilves, Anne Mattila, Jukka Rintala, Eliisa Löyttyniemi, Saija Hurme, Ville Tammilehto, Harri Marttila, Sanna Meriläinen, Johanna Laukkarinen, Eeva-Liisa Sävelä, Heini Savolainen, Tomi Sippola, Markku Aarnio, Hannu Paajanen, and Paulina Salminen.
• Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.
• JAMA. 2021 Jan 26; 325 (4): 353362353-362.

ImportanceAntibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, but the optimal antibiotic regimen is not known.ObjectiveTo compare oral antibiotics with combined intravenous followed by oral antibiotics in the management of computed tomography-confirmed uncomplicated acute appendicitis.Design, Setting, And ParticipantsThe Appendicitis Acuta (APPAC) II multicenter, open-label, noninferiority randomized clinical trial was conducted from April 2017 until November 2018 in 9 Finnish hospitals. A total of 599 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were enrolled in the trial. The last date of follow-up was November 29, 2019.InterventionsPatients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days.Main Outcomes And MeasuresThe primary end point was treatment success (≥65%) for both groups, defined as discharge from hospital without surgery and no recurrent appendicitis during 1-year follow-up, and to determine whether oral antibiotics alone were noninferior to intravenous and oral antibiotics, with a margin of 6% for difference.ResultsAmong 599 patients who were randomized (mean [SD] age, 36 [12] years; 263 [44%] women), 581 (99.7%) were available for the 1-year follow-up. The treatment success rate at 1 year was 70.2% (1-sided 95% CI, 65.8% to ∞) for patients treated with oral antibiotics and 73.8% (1-sided 95% CI, 69.5% to ∞) for patients treated with intravenous followed by oral antibiotics. The difference was -3.6% ([1-sided 95% CI, -9.7% to ∞]; P = .26 for noninferiority), with the confidence limit exceeding the noninferiority margin.Conclusion And RelevanceAmong adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics.Trial RegistrationClinicalTrials.gov Identifier: NCT03236961; EudraCT Identifier: 2015-003633-10.

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