Concurrent SARS-COV-19 and acute appendicitis: Management and outcomes across United States children’s hospitals

BACKGROUND: Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19–positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19–negative peers and to compare clinical outcomes and healthcare use for these groups. METHODS: A retrospective cohort study of children <18 years with acute appendicitis across 45 US Children’s Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management. RESULTS: Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19–positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7–16.8], P < .001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01–7.12], P < .001) and longer length of stay (median 2 days vs 1 day, P < .001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19–positive patients and 0% to 42% for COVID-19–negative patients. CONCLUSION: Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.