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evident
Original paper
2020NEJMSurgery/Perioperative

CODA

A randomized trial comparing antibiotics with appendectomy for appendicitis

RCTAppendicitis

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Overview

Antibiotics were noninferior to appendectomy for 30-day health status in appendicitis.

Clinical takeaway

CODA supports antibiotics as a reasonable option for selected appendicitis patients, while emphasizing recurrence and appendicolith risk in shared decision-making.

Key result

About 29% of patients assigned to antibiotics underwent appendectomy by 90 days.

Practice impact

Uncomplicated appendicitis can be a preference-sensitive choice rather than automatic surgery for every patient.

Evidence

Study design

Pragmatic randomized noninferiority trial.

Enrollment

1,552

Follow-up

Primary outcome at 30 days; appendectomy reported through 90 days.

Geography

United States

Clinical question

Are antibiotics noninferior to appendectomy for patient-reported health status in acute appendicitis?

Population

  • Adults with imaging-confirmed appendicitis, including patients with appendicolith.

Intervention

Antibiotics-first strategy (10-day course).

Comparator

Appendectomy.

Primary outcome

30-day EQ-5D health-status score.

Antibiotics were noninferior to appendectomy for 30-day EQ-5D health status (mean difference 0.01 points, 95% CI -0.001 to 0.03; noninferiority margin 0.05).

Mean difference / 0.01 / 95% CI -0.001 to 0.03

Key results

  • Antibiotics were noninferior to appendectomy for 30-day EQ-5D health status (mean difference 0.01 points, 95% CI -0.001 to 0.03; margin 0.05).
  • 29% of patients in the antibiotics group underwent appendectomy by 90 days (41% with an appendicolith, 25% without).
  • Complications were more common with antibiotics (8.1 vs 3.5 per 100 participants; rate ratio 2.28, 95% CI 1.30-3.98), driven by patients with an appendicolith (20.2 vs 3.6 per 100; rate ratio 5.69); without an appendicolith rates were similar (3.7 vs 3.5 per 100).

Harms

  • Need for later appendectomy was common after antibiotics.
  • Appendicolith was associated with higher complication and appendectomy risk.

Clinical Use

Practice impact

  • Made antibiotics-first management a mainstream shared decision for selected appendicitis patients.

Applicability

  • Adults with imaging-confirmed appendicitis who can follow up and understand recurrence/appendectomy risk.

Limitations

  • Not a blanket trial for perforated appendicitis, diffuse peritonitis, or inability to follow up.
  • The primary endpoint was health status, not definitive cure.

Common misinterpretations

  • Noninferior health status does not mean antibiotics cure appendicitis as reliably as appendectomy.

Related evidence

STOP-IT - ContextAPPAC - Earlier Trial

Citation

CODA Collaborative, Flum DR, Davidson GH, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020;383(20):1907-1919. doi:10.1056/NEJMoa2014320

Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03).