At the height of the COVID-19 pandemic, hospitals were flooded with critically ill patients suffering from the devastating effects of the virus. Medical providers and staff members across the country found themselves overworked and struggling to cope with deficits in manpower, time, space and equipment as COVID cases continued to climb amidst the normal workload. In order to prioritize the serious COVID cases, reduce the risk of exposure and infection to non-COVID patients and reduce provider exposure, it is necessary to consider new methods of treating routine disorders. One such routine disorder is appendicitis. While appendicitis can be potentially life-threatening and carry serious complications for certain patients, for other patients it carries less of a risk. Thus, new approaches at combating appendicitis are worth considering for those who may qualify. This is especially relevant in the COVID environment.
The traditional treatment of appendicitis, or inflammation of the appendix, is through surgery, whereby a surgeon removes the appendix either laparoscopically (minimally invasive procedure utilizing a long tube with a camera known as a laparoscope; this is generally the preferred method) or via the traditional open appendectomy (where there is a traditional incision) [1, 3]. There exists a common complication of appendicitis known as peritonitis, in which the appendix may rupture and release pus into the abdomen causing inflammation of the abdominal wall . This can result in high fever and intense pain for the patient. This condition requires emergency surgery to drain the pus from the abdomen and remove the appendix, and any alternative non-surgical treatments should not be considered in such cases [1,3].
However, for patients not facing the life-threatening impacts of peritonitis, and who do not have severely large abscesses or any other complications, antibiotics could potentially be a viable option to consider . A recent research report from the Digestive Surgery Department at Sorbonne University found evidence for the effectiveness of antibiotic treatments and developed a decision making model to assess which patients may be most suited for non-invasive options . They report that antibiotics can be considered for use on generally healthy individuals without major complications . This means that healthy individuals can avoid potentially dangerous trips to the hospital. It also means that delay of care for healthy patients can be greatly reduced, as these patients will not have to face the hesitancy of coming into a COVID-ridden emergency room or medical office.
According to researchers at Sorbonne University, antibiotics could also be useful for otherwise healthy COVID-19 patients who have comorbid appendicitis. Treating these patients with antibiotics can reduce provider exposure in the operating room. However, traditional surgery is still recommended for pregnant women, who are more likely to suffer sepsis, and for those who are unlikely to complete their full course of antibiotics. Not completing the full course can lead to the re-emergence of appendicitis . According to the researchers’ report, patients can be given oral Amoxicillin and clavulanic acid (a typical antibiotic for common infections) and discharged as soon as 24 hours after their initial visit, presuming they give informed consent . These findings are significant in that a reduction in unnecessary surgery provides additional availability and flexibility for providers to see critical COVID-19 patients.
Earlier work from S. Eriksson and L. Granstrom of the Department of Surgery at the Karolinska Institute found that antibiotic treatments are effective at treating appendicitis, but they can lead to a greater risk of re-emergence . They treated patients initially using IV antibiotics (specifically cefotaxime and tinidazole, and later ofloxacin and tinidazole) before sending them home. The patients who received antibiotics had less pain than their counterparts who received surgery . It is ultimately the decision of the provider and patient to decide whether an antibiotic treatment with less pain but a higher chance of re-emergence, or a more painful surgical option with no chance of re-emergence, should be taken. It is also worth noting that if the antibiotic treatment fails and appendicitis does re-emerge, and the patient in question has ready access to a hospital or surgical facility, surgical options can still be considered if necessary.
As mentioned previously, COVID-19 infection risk can possibly emerge as a concern when discussing treatment modality. However, it is imperative that the broader societal impacts of COVID-19 on rates of severe appendicitis and peritonitis are also addressed. Patients must weigh whether any abdominal pain they may be experiencing is severe enough to warrant a hospital visit and potential exposure, infection or death . As it might be expected, rates of complicated appendicitis have been higher in 2020 than in previous years because of the delay in initial treatment . It can be difficult to diagnose appendicitis over telehealth or in a physician office, as a CT scan is often required . Nonetheless, antibiotics can quickly be administered to patients and treatment can begin quickly without the need to wait for an operating room in those with non-complicated cases. Development of new diagnostic methods would greatly enhance the ability for appendicitis to be effectively managed.
In summary, antibiotics can be useful in generally healthy patients, as well as in select COVID-19 patients, who do not have complicated cases. Antibiotics can reduce the strain on the healthcare system during the COVID-19 pandemic by reducing the number of non-emergency surgeries for those who do not have peritonitis. They also provide a way for those to receive treatment who may be hesitant to risk exposure by coming to a hospital or medical office. These antibiotic treatments can be similarly effective, although the risks of potential re-emergence must be weighed for each patient individually.
Edited by: Isaac Mordukhovich
Illustrated by: Neha Adari