Appendiceal microbiome in uncomplicated and complicated acute appendicitis: A prospective cohort study

Sanja Vanhatalo, Eveliina Munukka, Teemu Kallonen, Suvi Sippola, Juha Grönroos, Jussi Haijanen, Antti J Hakanen, Paulina Salminen, Sanja Vanhatalo, Eveliina Munukka, Teemu Kallonen, Suvi Sippola, Juha Grönroos, Jussi Haijanen, Antti J Hakanen, Paulina Salminen

Abstract

Background: Uncomplicated and complicated acute appendicitis seem to be two different forms of this common abdominal emergency. The contribution of appendiceal microbiota to appendicitis pathogenesis has been suggested, but differences between uncomplicated and complicated appendicitis are largely unknown. We compared the appendiceal microbiota in uncomplicated and complicated acute appendicitis.

Methods: This prospective single-center clinical cohort study was conducted as part of larger multicenter MAPPAC trial enrolling adult patients with computed tomography or clinically confirmed uncomplicated or complicated acute appendicitis. The microbial composition of the appendiceal lumen was determined using 16S rRNA gene amplicon sequencing.

Results: Between April 11, 2017, and March 29, 2019, 118 samples (41 uncomplicated and 77 complicated appendicitis) were available. After adjusting for age, sex, and BMI, alpha diversity in complicated appendicitis was higher (Shannon p = 0.011, Chao1 p = 0.006) compared to uncomplicated appendicitis. Microbial compositions were different between uncomplicated and complicated appendicitis (Bray-Curtis distance, P = 0.002). Species poor appendiceal microbiota composition with specific predominant bacteria was present in some patients regardless of appendicitis severity.

Conclusion: Uncomplicated and complicated acute appendicitis have different appendiceal microbiome profiles further supporting the disconnection between these two different forms of acute appendicitis.

Study registration: ClinicalTrials.gov NCT03257423.

Conflict of interest statement

EM is currently working as full-time Medical Advisor for Biocodex Nordics. PS reports receiving personal fees for lectures form Merck and Orion Pharma. AJH reports receiving personal fees for lectures from BioCodex, Merck and Pfizer. This does not alter our adherence to PLOS ONE policies on sharing data and materials. All other authors declare no competing interests.

Figures

Fig 1. Flow chart of the study.
Fig 1. Flow chart of the study.
*Appendectomy for primary acute appendicitis. Only patients treated with appendectomy and histopathologically confirmed acute appendicitis study were included in the analysis to have the microbiological sample and to have confirmation for the differential diagnosis. a) Randomized, multicenter, open-label, noninferiority clinical trial comparing oral moxifloxacin with intravenous ertapenem followed by oral levofloxacin and metronidazole. b) Randomized, multicentre, placebo-controlled, double-blind trial comparing antibiotic therapy with placebo in the treatment of uncomplicated acute appendicitis.
Fig 2. The difference in appendiceal microbiota…
Fig 2. The difference in appendiceal microbiota between uncomplicated and complicated acute appendicitis.
A) Violin plot representing alpha diversity measures Shannon index and Chao1 in uncomplicated and complicated acute appendicitis. * p 0.1%). Species are listed along the y-axis and x-axis indicates the log2 fold change. UNK = unknown species.
Fig 3. Stacked barplots of appendiceal microbiome…
Fig 3. Stacked barplots of appendiceal microbiome (n = 118) in species level in uncomplicated and complicated acute appendicitis.
Microbiome profiles of individual appendix samples with the 40 most abundant species plotted and lower abundance species grouped to “other”. On top of barchart is overlaid the number of observed species in each sample as a line chart. UNK = unknown species.

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