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#370 Antibiotics or no antibiotics for acute diverticulitis, that is the question!


CLINICAL QUESTION
QUESTION CLINIQUE
 Do antibiotics change clinical outcomes for patients with acute uncomplicated diverticulitis?

BOTTOM LINE
RÉSULTAT FINAL
 For non-septic immunocompetent patients with acute uncomplicated diverticulitis, antibiotics do not alter early complication or recurrence rates.


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EVIDENCE
DONNÉES PROBANTES
  • Enrolled patients: Immunocompetent, symptoms compatible with acute, uncomplicated diverticulitis (confirmed on CT) without being septic/critically ill. Randomized to ~7 days antibiotics (cephalosporin/metronidazole or amoxicillin/clavulanic acid) or no antibiotics/placebo.
  • Systematic review (3 RCTs, 1329 patients):1
    • 30-day complications (abscess, perforation, obstruction, fistula): 1.5% versus 1.3% (no-antibiotics): Not statistically different.
    • Long term (2-11 year) risk of recurrence: ~24% both groups.
  • 3 largest, highest-quality RCTs:
    • 623 hospitalized adults from Sweden with first or recurrent acute uncomplicated diverticulitis:2
      • At 1 year, no statistical differences in:
        • Complications during hospitalization (examples: abscess/perforation): 1.0% versus 1.9% (no-antibiotics).
        • Median hospital stay (3 days each).
        • Recurrence (~16% each).
      • At 11 years (~90% of patients):3
        • No difference in recurrences (~31%), or surgery for diverticulitis (~5%).
    • 528 adults from the Netherlands with first diverticulitis episode:4
      • At 6 months, no statistical differences in:
        • Median time to recovery: 12 versus 14 days (no antibiotics).
        • Complicated diverticulitis: 2.6% versus 3.8% (no antibiotics).
        • Readmission rates: 12% versus 18% (no antibiotics).
      • At 24 months (~90% of patients):5
        • No difference in recurrences (~15%), complications, or surgery.
    • 480 adults from Spain in the emergency department with diverticulitis.6
      • At 3 months, no statistical differences in:
        • Hospitalization: 5.8% versus 3.3% (no-antibiotics).
        • Emergency surgery: None.
  • Limitations: Some RCTs unblinded.2,6
CONTEXT
CONTEXTE
  • Guidelines suggest against routine use of antibiotics in immunocompetent, non-medically frail patients with diverticulitis.7,8
  • Diverticulitis rates are increasing (especially in <50 years).9
    • Genetic factors appear to be involved in~50% of cases.8
    • Nuts, seeds, or popcorn do not appear to influence diverticulitis.10
  • The risk of colorectal cancer:11
    • Uncomplicated: ~0.5% (similar to asymptomatic controls).
    • Complicated: ~8%.
  • Complicated diverticulitis risk: Highest in first episode.9
  • Recurrence:9
    • After 1st episode ~17%.
    • After 2nd episode ~44%.

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Author(s)
Auteur(s)
  • Michael R Kolber MD CCFP MSc
  • Clarence K Wong MD FRCPC

1. Dichman M-L, Rosenstock SJ, Shabanzadeh DM. Cochrane Database Syst Rev. 2022; 6:CD009092. DOI: 10.1002/14651858.CD009092.

2. Chabok A, Pahlman L, Hjern F, et al. Br J Surg. 2012; 99:532–539.

3. Isacson D, Smedh K, Nikberg M, et al. Br J Surg. 2019; 106:1542–1548.

4. Daniels L, Ünlü C, de Korte N, et al. Br J Surg. 2017; 104:52–61.

5. van Dijk ST, Daniels L, Ünlü C, et al. Am J Gastroenterol. 2018; 113:1045–1052.

6. Mora-Lopez L, Ruiz-Edo N, Estrada-Ferrer O, et al. Ann Surg. 2021; 274:e435–e442.

7. Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, et al. Ann Intern Med. 2022; 175:399-415.

8. Peery AF, Shaukat A, Strate LL. Gastroenterology. 2021; 160:906–911.

9. Bharucha AE, Parthasarathy G, Ditah I, et al. Am J Gastroenterol. 2015; 110(11):1589–1596.

10. Strate LL, Liu YL, Syngal S, et al. JAMA. 2008; 300(8):907-914.

11. Rottier SJ, van Dijk ST, van Geloven AAW, et al. Br J Surg. 2019; 106:988-997.

Authors do not have any conflicts of interest to declare.