We have been prescribing antibiotics for diverticulitis for an eternity. Some patients, after all, do quite poorly without – and progress to perforation, sepsis, and death. Very few clamor for such an outcome. The question with diverticulitis has never been “antibiotics?”, only “inpatient or outpatient”?
Now, this dogmatic practice seems ripe to change.
This latest bit of published literature is an observational series from Sweden. These authors followed up their previously-published randomized trial with an initial foray into practice change, considering the consistent harms of antibiotic overuse. They prospectively enrolled 155 patients with CT-verified, uncomplicated diverticulitis and simply followed them after discharge without antibiotics. Management consisted solely of pain control, typically paracetamol (acetaminophen), an initial liquid diet, and then gradual progression to full diet as tolerated. Patients were followed daily by phone, at 1 week in clinic, and at 3 months again in clinic.
Of these 155 patients, there were a mere 4 treatment failures requiring admission. This treatment failure rate is similar to the ~2.5% rate expected with antibiotics. Two progressed to perforation and a third developed abscess – the last of which was apparent on re-review of the initial CT. Each patient with progression was treated with antibiotics as an inpatient and recovered.
This is, however, an observational trial, and there were another 66 patients diagnosed with uncomplicated diverticulitis in the same time period but missed for enrollment. This leads to concerns regarding selection bias, although the few presented clinical characteristics of the missed patients were similar to those included in the trial. Patients were also excluded on the basis of many comorbidities thought to increase the risk of treatment failure, and those treated as inpatients.
But, at the least, in this trial and those prior, there is clearly a cohort of uncomplicated diverticulitis that derives little benefit from antibiotics. And, furthermore, these few trials have not gone unnoticed: new guidelines in several countries, including the American Gastroenterological Association, have updates reflecting the validity of selective antibiotic use.
The evidence quality to date is still cumulatively low – but this is probably a treatment change paradigm just about ready for prime-time.
“Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study”
http://www.ncbi.nlm.nih.gov/pubmed/25989930
“American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis”
http://www.ncbi.nlm.nih.gov/pubmed/26453777