Central Surgical Association (CSA): Annual Meeting

DETROIT – Chest wall reconstruction that uses nonrigid mesh or autologous tissue without rigid fixation was safe and provided excellent respiratory outcomes in one of the largest series to date.

"Our recommendations are to reconstruct with autologous tissue alone whenever possible," Dr. Waël Hanna said. "If you have to use mesh because you cannot reapproximate the chest wall or there’s not enough muscle to construct a flap, then nonrigid mesh should be favored over rigid fixation."

Photo courtesy of Dr. DS Mulder 

Rigid fixation with methacrylate or metallic plates and screws has conventionally been advocated as the best method to achieve chest wall stability and to maintain respiratory integrity following resection of chest wall tumors. However, these approaches are frequently complicated by motion deformities of the shoulder girdle, long-term cosmetic deformities, pain that limits daily activities, and a high morbidity of infection, Dr. Hanna explained at the annual meeting of the Central Surgical Association.

He reported on 37 patients who underwent major chest wall reconstruction in 2003-2010 with autologous tissue alone or with a soft prosthetic mesh. No patient underwent rigid fixation with methacrylate or plates and screws. The study excluded patients with concomitant lung or pleural resection to avoid confounding the respiratory outcomes.

Nine patients had a small defect (less than 60 cm²) and 28 patients had a large defect (greater than 60 cm²); no defect measured exactly 60 cm², according to Dr. Hanna. The large-defect group was further divided into a subgroup of 16 patients who were reconstructed with soft mesh alone and a subgroup of 12 patients whose reconstruction was with autologous tissue alone and no mesh. Soft mesh was used in only one small-defect patient.

"We have turned away from using rigid prosthetics or methacrylate at our institution," said Dr. Hanna, a fifth-year resident with McGill University in Montreal.

Sarcoma was the most common indication for resection, followed by metastases to the chest wall, neurofibromas, and desmoid tumors. Reconstruction parameters were similar between the small- and large-defect cohorts, except for the mean size of the defect that was created in the chest wall (51 cm² vs. 149 cm²), the dissection of three or more ribs (0% vs. 50%), and the use of soft mesh only (11% vs. 61%). A muscle flap to cover the prosthesis was used equally in both cohorts (56% vs. 75%).

The rate of immediate postoperative extubation was similar, at 100% in the small-defect cohort and 89% in the large-defect cohort, Dr. Hanna said. Only one patient was reintubated on postop day 1 and remained intubated for 3 days in the ICU.

None of the small-defect group went to the ICU for ventilation or flap monitoring, whereas 11% and 18% of the large-defect cohort did (P = .006 for both subgroups).

Pneumonia developed in three patients with large defects and in none with small defects (11% vs. 0%). One patient had to be re-extubated postoperatively, he said.

Secondary outcomes were also similar between the small- and large-defect groups, including site infection (0% vs. 7%) and reoperation rates (0% vs. 11%).

A subgroup analysis comparing patients with and without mesh revealed no significant differences in the primary outcomes of immediate extubation (100% vs. 75%), ICU stay for ventilation (6% vs. 25%), ICU stay for flap monitoring (13% vs. 17%), or pneumonia (6% vs. 8%).

The mesh and no-mesh subgroups were also nonsignificantly different with regard to site infection (13% vs. 0%) and reoperation (19% vs. 0%).

After a mean follow-up of 42 months (range, 36-84 months), there were no reports of infections beyond 30 postoperative days, long-term pain, restriction of mobility, or cosmetic disturbances. Patients were seen every 3 months for the first 2 years and every 6 months thereafter.

"For chest wall defects smaller than 60 cm², reconstruction without a prosthesis has excellent outcomes," Dr. Hanna concluded. "For [defects] larger than 60 cm², there does not seem to be any major difference between autologous tissue alone vs. nonrigid prosthesis reconstruction.

Photo courtesy of Dr. DS Mulder 

"Finally, nonrigid mesh seems to offer better short-term and long-term outcomes," compared with the historical data on rigid fixation, he said.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Medical Center in Chicago asked how the surgeons manage the often catastrophic event of mesh infection, and whether any long-term pulmonary function data were available, as the defects would likely prompt the development of some degree of paradoxical chest wall motion, even with the soft mesh.

Dr. Hanna replied that the retrospective nature of the series did not allow pulmonary function testing, and that the thoracic surgery community views such testing as less than ideal after reconstruction of the chest wall. A better measure is home oxygen use or limitation of daily activities, neither of which were observed in the cohort.

Dr. Hanna agreed that mesh infection is a highly morbid situation, especially with methacrylate or metallic prostheses, and that one of the benefits of soft prostheses like Vicryl or Gore-Tex is that they are able to respond to antibiotics.

Dr. Gerald Larson of University Surgical Associates in Louisville, Ky., who was also invited to discuss the study, asked how closure was achieved when mesh and a flap were not used, and why mesh and a muscle flap weren’t used for all patients.

Dr. Hanna responded that the risk of surgical site infection kept them from closing all patients with mesh and a muscle flap. The ideal method for closure is to mobilize enough local muscle that is present in the chest wall to reapproximate the muscle, and to close with skin without having to rotate a pedicle flap. When this is impossible, the defect has to be filled, and most surgeons at his institution elect to use soft mesh for the larger defects.

"In 75% of the time, on top of the mesh, we still mobilize a subcutaneous flap to cover the mesh because of the theoretical perception that a flap on top of the mesh would provide a good oxygenated environment and would decrease the rate of infection," Dr. Hanna said. The risk of surgical site infection kept them from closing all patients with mesh and a muscle flap, he added.

Dr. Hanna and his coauthors reported no relevant conflicts of interest.

DETROIT – Chest wall reconstruction that uses nonrigid mesh or autologous tissue without rigid fixation was safe and provided excellent respiratory outcomes in one of the largest series to date.

"Our recommendations are to reconstruct with autologous tissue alone whenever possible," Dr. Waël Hanna said. "If you have to use mesh because you cannot reapproximate the chest wall or there’s not enough muscle to construct a flap, then nonrigid mesh should be favored over rigid fixation."

Photo courtesy of Dr. DS Mulder 

Rigid fixation with methacrylate or metallic plates and screws has conventionally been advocated as the best method to achieve chest wall stability and to maintain respiratory integrity following resection of chest wall tumors. However, these approaches are frequently complicated by motion deformities of the shoulder girdle, long-term cosmetic deformities, pain that limits daily activities, and a high morbidity of infection, Dr. Hanna explained at the annual meeting of the Central Surgical Association.

He reported on 37 patients who underwent major chest wall reconstruction in 2003-2010 with autologous tissue alone or with a soft prosthetic mesh. No patient underwent rigid fixation with methacrylate or plates and screws. The study excluded patients with concomitant lung or pleural resection to avoid confounding the respiratory outcomes.

Nine patients had a small defect (less than 60 cm²) and 28 patients had a large defect (greater than 60 cm²); no defect measured exactly 60 cm², according to Dr. Hanna. The large-defect group was further divided into a subgroup of 16 patients who were reconstructed with soft mesh alone and a subgroup of 12 patients whose reconstruction was with autologous tissue alone and no mesh. Soft mesh was used in only one small-defect patient.

"We have turned away from using rigid prosthetics or methacrylate at our institution," said Dr. Hanna, a fifth-year resident with McGill University in Montreal.

Sarcoma was the most common indication for resection, followed by metastases to the chest wall, neurofibromas, and desmoid tumors. Reconstruction parameters were similar between the small- and large-defect cohorts, except for the mean size of the defect that was created in the chest wall (51 cm² vs. 149 cm²), the dissection of three or more ribs (0% vs. 50%), and the use of soft mesh only (11% vs. 61%). A muscle flap to cover the prosthesis was used equally in both cohorts (56% vs. 75%).

The rate of immediate postoperative extubation was similar, at 100% in the small-defect cohort and 89% in the large-defect cohort, Dr. Hanna said. Only one patient was reintubated on postop day 1 and remained intubated for 3 days in the ICU.

None of the small-defect group went to the ICU for ventilation or flap monitoring, whereas 11% and 18% of the large-defect cohort did (P = .006 for both subgroups).

Pneumonia developed in three patients with large defects and in none with small defects (11% vs. 0%). One patient had to be re-extubated postoperatively, he said.

Secondary outcomes were also similar between the small- and large-defect groups, including site infection (0% vs. 7%) and reoperation rates (0% vs. 11%).

A subgroup analysis comparing patients with and without mesh revealed no significant differences in the primary outcomes of immediate extubation (100% vs. 75%), ICU stay for ventilation (6% vs. 25%), ICU stay for flap monitoring (13% vs. 17%), or pneumonia (6% vs. 8%).

The mesh and no-mesh subgroups were also nonsignificantly different with regard to site infection (13% vs. 0%) and reoperation (19% vs. 0%).

After a mean follow-up of 42 months (range, 36-84 months), there were no reports of infections beyond 30 postoperative days, long-term pain, restriction of mobility, or cosmetic disturbances. Patients were seen every 3 months for the first 2 years and every 6 months thereafter.

"For chest wall defects smaller than 60 cm², reconstruction without a prosthesis has excellent outcomes," Dr. Hanna concluded. "For [defects] larger than 60 cm², there does not seem to be any major difference between autologous tissue alone vs. nonrigid prosthesis reconstruction.

Photo courtesy of Dr. DS Mulder 

"Finally, nonrigid mesh seems to offer better short-term and long-term outcomes," compared with the historical data on rigid fixation, he said.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Medical Center in Chicago asked how the surgeons manage the often catastrophic event of mesh infection, and whether any long-term pulmonary function data were available, as the defects would likely prompt the development of some degree of paradoxical chest wall motion, even with the soft mesh.

Dr. Hanna replied that the retrospective nature of the series did not allow pulmonary function testing, and that the thoracic surgery community views such testing as less than ideal after reconstruction of the chest wall. A better measure is home oxygen use or limitation of daily activities, neither of which were observed in the cohort.

Dr. Hanna agreed that mesh infection is a highly morbid situation, especially with methacrylate or metallic prostheses, and that one of the benefits of soft prostheses like Vicryl or Gore-Tex is that they are able to respond to antibiotics.

Dr. Gerald Larson of University Surgical Associates in Louisville, Ky., who was also invited to discuss the study, asked how closure was achieved when mesh and a flap were not used, and why mesh and a muscle flap weren’t used for all patients.

Dr. Hanna responded that the risk of surgical site infection kept them from closing all patients with mesh and a muscle flap. The ideal method for closure is to mobilize enough local muscle that is present in the chest wall to reapproximate the muscle, and to close with skin without having to rotate a pedicle flap. When this is impossible, the defect has to be filled, and most surgeons at his institution elect to use soft mesh for the larger defects.

"In 75% of the time, on top of the mesh, we still mobilize a subcutaneous flap to cover the mesh because of the theoretical perception that a flap on top of the mesh would provide a good oxygenated environment and would decrease the rate of infection," Dr. Hanna said. The risk of surgical site infection kept them from closing all patients with mesh and a muscle flap, he added.

Dr. Hanna and his coauthors reported no relevant conflicts of interest.

DETROIT – Chest wall reconstruction that uses nonrigid mesh or autologous tissue without rigid fixation was safe and provided excellent respiratory outcomes in one of the largest series to date.

"Our recommendations are to reconstruct with autologous tissue alone whenever possible," Dr. Waël Hanna said. "If you have to use mesh because you cannot reapproximate the chest wall or there’s not enough muscle to construct a flap, then nonrigid mesh should be favored over rigid fixation."

Photo courtesy of Dr. DS Mulder 

Rigid fixation with methacrylate or metallic plates and screws has conventionally been advocated as the best method to achieve chest wall stability and to maintain respiratory integrity following resection of chest wall tumors. However, these approaches are frequently complicated by motion deformities of the shoulder girdle, long-term cosmetic deformities, pain that limits daily activities, and a high morbidity of infection, Dr. Hanna explained at the annual meeting of the Central Surgical Association.

He reported on 37 patients who underwent major chest wall reconstruction in 2003-2010 with autologous tissue alone or with a soft prosthetic mesh. No patient underwent rigid fixation with methacrylate or plates and screws. The study excluded patients with concomitant lung or pleural resection to avoid confounding the respiratory outcomes.

Nine patients had a small defect (less than 60 cm²) and 28 patients had a large defect (greater than 60 cm²); no defect measured exactly 60 cm², according to Dr. Hanna. The large-defect group was further divided into a subgroup of 16 patients who were reconstructed with soft mesh alone and a subgroup of 12 patients whose reconstruction was with autologous tissue alone and no mesh. Soft mesh was used in only one small-defect patient.

"We have turned away from using rigid prosthetics or methacrylate at our institution," said Dr. Hanna, a fifth-year resident with McGill University in Montreal.

Sarcoma was the most common indication for resection, followed by metastases to the chest wall, neurofibromas, and desmoid tumors. Reconstruction parameters were similar between the small- and large-defect cohorts, except for the mean size of the defect that was created in the chest wall (51 cm² vs. 149 cm²), the dissection of three or more ribs (0% vs. 50%), and the use of soft mesh only (11% vs. 61%). A muscle flap to cover the prosthesis was used equally in both cohorts (56% vs. 75%).

The rate of immediate postoperative extubation was similar, at 100% in the small-defect cohort and 89% in the large-defect cohort, Dr. Hanna said. Only one patient was reintubated on postop day 1 and remained intubated for 3 days in the ICU.

None of the small-defect group went to the ICU for ventilation or flap monitoring, whereas 11% and 18% of the large-defect cohort did (P = .006 for both subgroups).

Pneumonia developed in three patients with large defects and in none with small defects (11% vs. 0%). One patient had to be re-extubated postoperatively, he said.

Secondary outcomes were also similar between the small- and large-defect groups, including site infection (0% vs. 7%) and reoperation rates (0% vs. 11%).

A subgroup analysis comparing patients with and without mesh revealed no significant differences in the primary outcomes of immediate extubation (100% vs. 75%), ICU stay for ventilation (6% vs. 25%), ICU stay for flap monitoring (13% vs. 17%), or pneumonia (6% vs. 8%).

The mesh and no-mesh subgroups were also nonsignificantly different with regard to site infection (13% vs. 0%) and reoperation (19% vs. 0%).

After a mean follow-up of 42 months (range, 36-84 months), there were no reports of infections beyond 30 postoperative days, long-term pain, restriction of mobility, or cosmetic disturbances. Patients were seen every 3 months for the first 2 years and every 6 months thereafter.

"For chest wall defects smaller than 60 cm², reconstruction without a prosthesis has excellent outcomes," Dr. Hanna concluded. "For [defects] larger than 60 cm², there does not seem to be any major difference between autologous tissue alone vs. nonrigid prosthesis reconstruction.

Photo courtesy of Dr. DS Mulder 

"Finally, nonrigid mesh seems to offer better short-term and long-term outcomes," compared with the historical data on rigid fixation, he said.

Invited discussant Dr. Fred Luchette, professor of surgery at Loyola University Medical Center in Chicago asked how the surgeons manage the often catastrophic event of mesh infection, and whether any long-term pulmonary function data were available, as the defects would likely prompt the development of some degree of paradoxical chest wall motion, even with the soft mesh.

Dr. Hanna replied that the retrospective nature of the series did not allow pulmonary function testing, and that the thoracic surgery community views such testing as less than ideal after reconstruction of the chest wall. A better measure is home oxygen use or limitation of daily activities, neither of which were observed in the cohort.

Dr. Hanna agreed that mesh infection is a highly morbid situation, especially with methacrylate or metallic prostheses, and that one of the benefits of soft prostheses like Vicryl or Gore-Tex is that they are able to respond to antibiotics.

Dr. Gerald Larson of University Surgical Associates in Louisville, Ky., who was also invited to discuss the study, asked how closure was achieved when mesh and a flap were not used, and why mesh and a muscle flap weren’t used for all patients.

Dr. Hanna responded that the risk of surgical site infection kept them from closing all patients with mesh and a muscle flap. The ideal method for closure is to mobilize enough local muscle that is present in the chest wall to reapproximate the muscle, and to close with skin without having to rotate a pedicle flap. When this is impossible, the defect has to be filled, and most surgeons at his institution elect to use soft mesh for the larger defects.

"In 75% of the time, on top of the mesh, we still mobilize a subcutaneous flap to cover the mesh because of the theoretical perception that a flap on top of the mesh would provide a good oxygenated environment and would decrease the rate of infection," Dr. Hanna said. The risk of surgical site infection kept them from closing all patients with mesh and a muscle flap, he added.

Dr. Hanna and his coauthors reported no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Uncomplicated acute appendicitis can be safely treated by antibiotics alone, a systematic meta-analysis suggests.

Use of antibiotics may prevent unnecessary appendectomy and reduce overall complication rates, lead author Dr. Katherine J. Liu said at the annual meeting of the Central Surgical Association.

"Appendectomy may be reserved for antibiotic treatment failure and recurrent appendicitis," she said.

Dr. Liu pointed out that antibiotics have become progressively more powerful in the last 30 years and that spontaneous resolution of acute appendicitis occurs in 24-48 hours without any treatment in up to 20% of patients in large series. A recently published study found that the negative appendectomy rate in the era of computed tomography is 5% with CT and 10% without CT (Ann. Surg. 2008;248:557-63). Also, perforated and nonperforated appendicitis are probably two separate disease entities, based on several very large epidemiologic studies, she said.

The authors identified 398 studies in 1970-2009 that reported antibiotics in the treatment of acute appendicitis. Only six studies compared antibiotic treatment with appendectomy and met the selection criteria. Studies were excluded if they did not specify patient selection criteria, included patients with known abscess or symptoms for more than 3 days prior to presentation, or included only pediatric patients.

The six remaining trials included four randomized, one prospective, and one retrospective study, comprising 1,201 patients. Methodological quality was assessed by the Newcastle-Ottawa Scale, resulting in a mean score of 6.8.

The complication rate in all six studies was lower for antibiotic treatment (range, 0%-21%) than for appendectomy (range, 4.4%-34%). In five studies, complications occurred only in patients who had antibiotic treatment failure, interval appendectomy, or appendectomy for recurrence, said Dr. Liu, professor of surgery at Rush University in Chicago. No patient in either treatment group died, and all were followed for at least 1 year.

The average antibiotic failure rate was 7% (range, 5%-12%), and the average recurrence rate was 14% (range, 5.3%-35%) among the 433 patients in the antibiotic group. Two of the patients who were judged to be antibiotic-treatment failures were found to have normal appendix at appendectomy. None of the patients who failed to respond to antibiotics had perforation at appendectomy in one of the studies, suggesting that there might have been an overestimation of antibiotic failure, she said.

A normal appendix was identified in an average of 7.3% of patients undergoing appendectomy (range, 3.2%-15%).

Dr. Liu acknowledged that the meta-analysis had several limitations: Different types of studies were included, patients might not have been comparable in the two treatment groups, and the definition of complications may have varied among studies. In addition, antibiotic regimens and treatment duration were varied, and the criteria for antibiotic treatment failure might have been different.

"Nonetheless, all six studies consistently demonstrated that uncomplicated acute appendicitis can be safely treated by antibiotics alone," Dr. Liu concluded. "Antibiotics may avoid unnecessary appendectomy and its associated morbidity and mortality in up to 25% of patients."

Invited discussant Dr. C. Max Schmidt, a surgeon at Indiana University in Indianapolis, asked what the rate of serious complications was and what Dr. Liu recommends for clinicians who treat adult appendicitis.

Major complications were reported in only one study, with 29 complications occurring in 10% of patients treated for appendectomy. Three major complications occurred in 2.5% of patients treated with antibiotics, but all three events were from subsequent appendectomy, she said.

Dr. Liu currently treats acute uncomplicated appendicitis with surgery, unless risk factors (such as morbid obesity or smoking) are present that would increase the risk of complications or mortality. Dr. Liu said that the study was sparked by just such a case involving a 70-year-old man who had chronic obstructive pulmonary disease, was on home oxygen, and had a surgical mortality risk that was estimated to be 50% by the medical consult. So she decided to give antibiotic treatment a try and was surprised to find that the patient responded successfully.

When pressed by the audience of surgeons on whether surgery should remain the standard of care for acute uncomplicated appendicitis, Dr. Liu said that standard of care is dependent on how one’s peers would treat a particular patient. Ultimately, she said, surgery should be the first choice in most cases, but surgeons should be open to the possibility of using antibiotics, and she likened the potential paradigm shift away from automatic surgery for appendicitis to that observed in the treatment of diverticulitis. Dr. Liu also called for prospective randomized trials to clarify the role of appendectomy and antibiotic treatment in appendicitis.

Finally, the provocative study elicited a series of personal anecdotes from the audience, including a surgeon who used antibiotics to successfully treat an attorney who refused appendectomy because he was arguing a case before the Supreme Court the next day. A Canadian surgeon told the story of Patrick Roy, a star goalie who was successfully managed with antibiotics during a Stanley Cup match, prompting fellow Canadians to demand the nonoperative treatment for their appendicitis. The situation got so out of hand that the Quebec Association of Surgeons issued a statement that antibiotics are not appropriate treatment for all cases of appendicitis.

Yet before the conversation could sway the crowd too far from its surgical roots, an attendee reminded the audience that they were sitting just a few miles from Detroit’s Grace Hospital, where Harry Houdini died in 1926 as a result of peritonitis secondary to a ruptured appendix (albeit before the advent of antibiotics).

The authors disclosed no relevant conflicts of interest.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Despite a decreasing incidence of inpatients with Clostridium difficile colitis, hospital costs associated with caring for these patients continues to rise.

A large propensity score matched analysis found that mean Clostridium difficile colitis (CDC) admissions decreased by 13% from 2005 to 2008 in Pennsylvania, while the mean per admission costs for CDC patients rose by 9%.

Mean hospital costs per admission were $22,094 for patients with CDC vs. $10,865 for those without the infection.

"For each study year, CDC costs were consistently 50% higher than for non-CDC patients," Dr. David B. Stewart said at the annual meeting of the Central Surgical Association.

Notably, only 450 of the CDC patients, or less than 1%, underwent total colectomy for their infection.

Dr. Stewart and his colleagues at Pennsylvania State Hershey Medical Center in Hershey used the Pennsylvania Health Care Cost Containment Council (PHC4) database to identify CDC cases from 2005 to 2008 and study factors associated with CDC costs. Cost-to-charge ratios were used to derive per admission costs from hospital charges and were inflation adjusted to 2008 dollar values.

For 2005-2008, there were 7,227,788 hospital admissions in Pennsylvania, of which 78,273 patients, or 1.08%, had primary or secondary CDC. More than 75% of all patients were at least 65 years of age and had Medicaid as a payer. More than half, or 57%, were female and 87% were white.

Most of the hospitals were large (68%) and located in an urban setting (90%), while a minority (27%) were teaching hospitals, said Dr. Stewart, who specializes in colon and rectal surgery. Urban vs. rural setting was based on U.S. census definitions, and hospital size was based on Healthcare Cost and Utilization Program designation.

The analysis revealed that costs varied by hospital type. Small facilities had the highest costs overall at a mean of $25,465 per case compared with $20,160 for medium hospitals and $22,068 for large hospitals, he said.

Based on teaching status alone, teaching hospitals had significantly greater costs per CDC case at $33,528 vs. $17,854 for nonteaching hospitals .

Based on setting, urban hospitals had significantly higher costs at $23,194 vs. $11,969 for rural hospitals. In part, this is explained by the fact that urban and teaching hospitals had significantly higher Charlson Comorbidity Index scores among their patients than did rural and nonteaching facilities, Dr. Stewart said.

Overall, the heavy rural makeup of Pennsylvania, patient demographics, and the distribution of hospitals also lend themselves to higher costs for treating CDC. Out of 200 hospitals in the database, only 25 were designated as teaching facilities. Teaching hospitals cared for a disproportionate percentage, or 27%, of CDC admissions, he noted. None of the rural hospitals were designated as teaching facilities. Subsequently, rural patients with CDC had to travel roughly twice as far as urban residents for their care.

In linear regression and multivariable analysis, factors significantly associated with higher attributable excess costs for CDC included age less than 18 years, male gender, ethnicity other than white or African American, elective hospital admission, Medicaid payer type, a Charlson comorbidity index of 3 or more, urban hospital setting, and small hospital setting.

The biggest detriment to CDC research is the complete dearth of information regarding such prognostic factors as bacterial virulence factors, toxin type, and sensitivities to antibiotics that would help to explain the disease manifestations clinicians are observing in their patients, Dr. Stewart said. This is a reflection of the rapid change the disease has undergone over the last 2 decades, creating a great deal of uncertainty about the disease.

"If you had to describe the state of CDC management at this time, unfortunately, you would have to characterize it as being roughly empiric treatment," he said. "We’re using the same antibiotics we did 20 years ago when they worked better, and we have no diagnostic tools with which to differentiate any one patient’s infection from anyone else’s.

"This creates a great deal of uncertainty into the disease process and disease course, and as such, it might be wise if we began to look at CDC like we do other potentially surgical diseases like adhesive small bowel obstructions or diverticulitis, where the preferential treatment is nonoperative, but it mandates the early or even principal involvement of a surgeon."

This might also have implications as to where CDC patients are admitted and how early in their course they are transferred to other facilities, he said.

During a discussion of the study, it was asked whether the presence of particularly virulent strains such as B1/NAP1 may be driving up hospital costs overall. Dr. Stewart said that according to preliminary data from 25 tissue samples he’s analyzed and typed at his institution, 82% were NAP1 and had such virulence characteristics as the presence of binary toxin, toxins A&B, and very low minimal inhibitory concentrations for metronidazole (Flagyl) and vancomycin (Vancocin). Still, patients with these strains were no more likely to require ICU care, to undergo surgery or to have longer hospital stays, he said, noting that his institution does only about 10 colectomies per year.

The authors reported no relevant financial disclosures.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.

DETROIT – Preinjury use of warfarin, but not aspirin or clopidogrel, significantly increased the risk of death in a retrospective analysis of 3,488 trauma patients.

Overall, mortality was 13.6% for patients on warfarin (Coumadin), aspirin, clopidogrel (Plavix), or various combinations, compared with 6.2% for patients not on these medications.

When mortality data were broken down by drug, warfarin demonstrated a mortality of 24% vs. 6% for controls.

After they adjusted for the potential confounders of age and injury severity score, the researchers found that the relative risk of a patient on warfarin dying during hospitalization as a result of their injury remained significant at 3.9, first-year resident Dr. Travis Arnold reported on behalf of his colleagues and lead author Dr. Carrie Jahraus at Albany (N.Y.) Medical College.

Surprisingly, aspirin and clopidogrel were not significantly associated with increased mortality at 12.3% and 9.3%, respectively, when adjusted for confounders.

"With aspirin and, [perhaps] clopidogrel, there may be some protective mechanism that we don’t fully understand," senior author Dr. Daniel Bonville said in an interview, adding that other groups have found similar results for the two agents.

All of the drugs increased the risk of intracranial hemorrhage when compared with controls (50% vs. 30%). The adjusted relative risk was 3.2 for warfarin, 1.9 for patients on warfarin plus clopidogrel, and 1.6 for those on aspirin or other combinations.

A total of 3,488 trauma patients were identified in the Albany Medical College database from September 2004 to December 2007. Of these, 456 patients were on some form of anticoagulation or antiplatelet therapy including 91 patients on warfarin alone, 228 on aspirin, 43 on clopidogrel, and 94 on various combinations. The mean warfarin international normalized ratio (INR) level was within the therapeutic window at 2.4, with 95% of patients falling between 2.2 and 2.6, Dr. Arnold said.

The percentage of patients in the treatment and control groups who experienced a blunt trauma was similar at 99% vs. 93%, respectively, as was the percentage with Injury Severity Scores greater than 15 (55% vs. 50%, respectively).

Hospital length of stay greater than 10 days was similar at 30% for the treatment group vs. 24% for controls, and remained similar after adjustment, Dr. Arnold said.

The percentage of patients discharged to home was significantly lower at 48% among patients on warfarin and antiplatelet agents vs. 74% for controls (P less than .01). This difference disappeared when adjusted for age.

When the researchers compared the subgroup of 191 patients who had intracranial hemorrhage with controls, only warfarin increased mortality (29% vs. 6%, adjusted RR 3.1) and the need for craniotomy (15% vs. 7%, adjusted RR 2.2), Dr. Arnold said.

He concluded that warfarin continues to be a necessary evil for many patients with coronary artery disease or history of stroke and advocated for greater patient education by primary care providers on the risks of anticoagulants.

Invited discussant Dr. Mark Hemmila, with the University of Michigan, Ann Arbor, said it is fortunate that only warfarin increases the risk of mortality given how difficult it is to reverse the effects of aspirin and clopidogrel, but that he would rank clopidogrel ahead of Coumadin and aspirin in terms of dangerousness. He asked Dr. Arnold to speculate on why no effect was observed and how the researchers recommend evaluating patients on warfarin.

Dr. Arnold said if a patient is on warfarin and has significant trauma and an elevated INR, warfarin reversal is initiated prior to obtaining computed tomography imaging. Factor VII is used, although they are transitioning more to the prothrombin complex. He said it is unclear why no impact on mortality was observed for aspirin given the large number of aspirin users in the study and that an effect would likely have been observed had there been more clopidogrel patients.

A recent analysis of 1.2 million patients in the American College of Surgeons’ National Trauma Data Bank reported that warfarin was associated with an increased risk of death, regardless of type of injury, indication for anticoagulation, or comorbidities. In all, 9.3% of warfarin-users died from their injuries vs. 4.8% of nonusers (Arch. Surg. 2011 [doi:10.1001/archsurg.2010.313]).

The researchers disclosed no conflicts of interest.