Nonoperative treatment (NOT) of acute uncomplicated appendicitis (AUA) refers to treatments involving prescription of antibiotics only, typically those with aerobic and anaerobic coverage of common bacteria commonly found in the bowel. Examples include treatments with amoxicillin and clavulanic acid, piperacillin sodium and tazobactam sodium, or ciprofloxacin hydrochloride and metronidazole hydrochloride. In the Appendicitis Acuta (APPAC) randomized controlled trial [1], intravenous ertapenem was administered for 3 days, followed by 7 days of oral levofloxacin and metronidazole. A combination of intravenous ceftriaxone and metronidazole was used in another study [2].

In South Asian countries, AUA is diagnosed using clinical features, physical examinations, total blood count, and ultrasonograms during outpatient checkups. Complicated appendicitis is considered if there is evidence of appendix perforation, abscess formation, localized peritonitis, or lump formation on clinical examinations supported by ultrasonogram. NOT is considered if diagnosis was clinically suspected as appendicitis plus leukocytosis, with confirmation by ultrasonogram. Patients are asked to report to the outpatient department after 7 days of treatment or to the emergency department in case of worsening conditions. NOT is abandoned when no improvement with antibiotics, clinical deterioration, and development of signs and symptoms of complicated appendicitis are observed.

However, treating pediatric acute appendicitis nonoperatively, rather than by open or laparoscopic appendectomy, still elicits great debate [3-5] spawned by the results of controlled trials and observational studies [6-10], reviews [11-14], and meta-analyses [15-17]. The year 2020 has provided a unique opportunity in which some of this opinion bias, particularly against NOT, can be partially removed. In a recent editorial, the pandemic was considered to provide an opportunity for the ultimate trial for NOT [18]. COVID-19, which is caused by SARS-CoV-2, emerged from Wuhan, China, in December 2019. As of November 2021, the infection has spread globally, with over 250 million confirmed cases resulting in over 5 million deaths worldwide [19]. The response to the pandemic has affected all social and economic aspects of life. However, it has also significantly affected health care facilities [20] in several ways, such as reallocation of hospital facilities to accommodate the influx of COVID-19 patients as well as reducing the number of procedures that would normally be carried out as a result of the repurposing of rooms and maintaining of social distancing protocols to mitigate the spread of the virus. Nearly all countries (90%) have experienced such disruptions to their health services, with low- and middle-income countries reporting the greatest difficulties [20]. This effect has particularly strained surgeries, in general [20,21], and, thus, would have a direct effect on treatment strategies for pediatric AUA. The objective of this study was to determine the effect of the COVID-19 pandemic on the approaches of care for AUA in the South Asian countries of Bangladesh, India, Nepal, and Pakistan, and to determine if any permanent changes in opinions of care will result once the effects of the pandemic have diminished.

The instrument used in this study was a voluntary survey with no added incentives; the survey was administered via SurveyMonkey (Momentive), a leading provider of survey software and tools, and was sent to 200 pediatric surgeons in Bangladesh, India, Pakistan, and Nepal. The invitation to participate was sent via email, mobile SMS, Facebook Messenger, and WhatsApp to physicians on mailing lists and to physicians in all coauthors’ personal networks. In the invitation, prospective respondents were told the length of time the survey would be available, which data would be stored, the data storage location, and for how long data would be kept. No personal information was collected. The purpose of the study was explained, and the investigators were identified. The open survey consisted of 10 nonrandomized questions pertaining to the respondents’ position, type of institute, and country of practice; the number of appendicitis cases they managed between April 1 and August 31 in 2019 and 2020; and the number and percentage of those cases that were treated nonoperatively—responses were binned within 10% increments. Respondents were able to change their responses prior to submission and were also alerted to any missed or skipped questions. Data were collected over a 2-week period from September 14 to 28, 2020; each participant was given a unique anonymous identifier. The survey questions were conceived and developed by all coauthors, but no statistical validation was performed. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) checklist [22] for the survey is included in Multimedia Appendix 1. The final question posed to each pediatric surgeon was whether they would maintain their current COVID-19–imposed level of NOT once the effect of the pandemic on their ability to perform surgery subsides. The study was approved by the Ethics Committee of South Point Hospital, Chittagong, Bangladesh (No. Admn/SPH/190/2020).

The survey response data were analyzed using JMP software (version 15.2; SAS Institute Inc). There was no weighting of responses assigned to certain questions. We use matched-pair tests for each respondent and analyzed the results using a Wilcoxon signed-rank test. The analyses were performed ungrouped and grouped by country, type of institute, and position.

A total of 134 out of 200 physicians responded to the survey, representing a 67.0% response rate. There were no missing data. Respondents’ positions, types of institute, and countries of practice are summarized in Table 1.

The change in usage of NOT by each physician in the entire cohort, as well as grouped by position, institution type, and country, is depicted by the heat maps in Figure 1, A to D, respectively. The values in each box represent the percentage of physicians. Boxes that lie completely above the diagonal represent physicians who increased their usage of NOT during the pandemic. The results from the Wilcoxon signed-rank tests are given in Table 2 for the entire cohort as well as grouped by position, institute, and country. There was a significant increase in the percentage of appendicitis cases treated nonoperatively from April 1 to August 31, 2020, compared to the same time period in 2019 (P<.001), as clearly observed in Figure 1, A. Though it appears there may be some differences when the cohort is grouped by type of institute or country (Figure 1, C and D), these were not found to be significant (P=.65 within pairs and P=.52 among pairs for type of institute; P=.65 within pairs and P=.52 among pairs for country). When grouping by position, we found a weak significance within pairs (P=.06), which compares the differences between pairs in a group, but not among pairs (P=.12), which compares the averages of the pairs between groups.

This potentially interesting effect of the position grouping is shown in more detail in the matched-pair plot in Figure 2. As this is grouped data, the y-axis reports the mean of the differences between the groups, and the x-axis represents the mean of the means. For clarity, the data points have been removed and only the group labels are plotted. The dotted red lines indicate the boundaries of the 95% CI, and the solid line represents the mean for the entire cohort. It should be noted that the upper 95% CI value falls below zero. Not only does this plot clearly show that the percentage of appendicitis cases treated nonoperatively has significantly increased in 2020, but it also indicates that professors, consultants, and associate professors were most likely to expand their use of NOT. This is also evident from Figure 1, B.

Also interesting are the results from the final question as to whether or not the physicians would consider maintaining the COVID-19–imposed level of NOT for appendicitis after the effects of the pandemic on surgery capability subside. An interesting result from this points to the level and spirit of opinion on the topic of NOT, in general. Though the respondents were given the option of replying “don’t know” or “no comment,” the majority (126/134, 94.0%) responded with a definitive “yes” or “no.” The fractions of those grouped by position, institute, and country are shown in the mosaic plots in Figure 3. As in the matched-pair analysis, no association was found using the Fisher exact test between institute (P=.99) or country (P=.37) and a planned change in the level of NOT practice after the effects of the pandemic subside. However, a significant association was found for position (P=.04). The mosaic plot in Figure 3 shows that residents were the least likely, and professors the most likely, to retain their current level of NOT postpandemic.

The data sets generated and analyzed during this study are available online [23].