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
Well this set of guidelines is so saddening. Most recommendations are "Conditional recommendation, low quality of evidence" or "very low"
I'm waiting to see the methods in the Viking study. What is the difference between a liquid and solid diet past the duodenum ?
I've never undestood why gastroenterologists recommend a fiber devoid diet in patients with acute diverticulitis let alone after such an episode , for prevention.
We now tend to acknowledge the value of looking at "All cause mortality" in intervention/drug studies. We don't want or shouldn't want to have say, less MIs in a statin treated population and less cardiovascular deaths (in case this were true oops), abut an increased total mortality .
Fiber is part of most diets assocaited or RCT proven to reduce all cause mortality so why preach against fibers ?
Maybe I 've missed the literature that shows high fiber diets cause acute diverticulitis or cause them to perforate ?
Hm – I tend to appreciate guidelines that appropriately reflect the quality of evidence. Contrast to some of the AHA guidelines persistently failing to acknowledge the limitations in data (e.g., compare the ACEP tPA review with the AHA version).
I'm not sure I read these guidelines as discouraging fiber. They simply acknowledge the quality of evidence being low. Same with nuts – no need to avoid nuts, either – but the evidence quality is also low.
I did'nt read the guideines as discouraging fiber either , but was alluding to gastropods (here, maybe everywhere) swear by the no fiber diet. For acute diverticulitis and afterward. And they disseminate that message, the rationale of which I just don't get.
Now when the guidelines will be quoted, will the evidence level be quoted too?