Controversy in the classification of appendicitis and utilization of postoperative antibiotics

Infographic · Jul 2022 · 1 min read

In brief

Survey of 562 surgeons reveals poor agreement on appendicitis classification and postoperative antibiotic use, with 59% prescribing antibiotics after non-complicated appendectomy despite lack of evidence. Findings highlight need for standardized classification systems and antibiotic protocols to reduce practice variation and unnecessary antibiotic exposure.

Surgeons show poor agreement on appendicitis classification, especially distinguishing perforated from nonperforated cases (alpha=0.45)
59% of surgeons prescribe postoperative antibiotics for non-gangrenous/non-perforated appendicitis despite lack of evidence
Antibiotic use varies widely: 14% prescribe for inflamed appendix, 44% for suppurative, 75% for gangrenous, 97% for perforated
Years in practice (16+) was the only factor significantly associated with postoperative antibiotic prescribing patterns
Lack of standardized classification hinders research and contributes to antibiotic overuse in pediatric and adult appendectomy

Written by the GCMD Library team from the infographic.

The infographic uses a clean layout with anatomical illustrations of the appendix in three states (normal, perforated, and with antibiotics). Gray and navy blue human figures represent survey participants. Red thumbs-down icons emphasize poor agreement scores. Alpha coefficients are displayed prominently for each diagnostic category.

Background

There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees.

Methods

A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff’s alpha for interrater agreement, and logistic regression.

Results

In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff’s alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff’s alpha = 0.45).

Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff’s alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice.

Conclusions

Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics.

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