#370 Antibiotics or no antibiotics for acute diverticulitis, that is the question!
CLINICAL QUESTION
Do antibiotics change clinical outcomes for patients with acute uncomplicated diverticulitis?
BOTTOM LINE
For non-septic immunocompetent patients with acute uncomplicated diverticulitis, antibiotics do not alter early complication or recurrence rates.
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EVIDENCE
- 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%).
- At 1 year, no statistical differences in:
- 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.
- At 6 months, no statistical differences in:
- 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.
- At 3 months, no statistical differences in:
- 623 hospitalized adults from Sweden with first or recurrent acute uncomplicated diverticulitis:2
- Limitations: Some RCTs unblinded.2,6
CONTEXT
- 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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When a patient who has had nagging LLQ pain for a few weeks reports a reduction of pain in 2 or 3 days after starting metronidazole and amoxi-clav, and this clinical scenario is repeated many times over one’s 43 years of practice, it becomes hard to imagine that the leave-it-be approach is right in the majority of cases. I’ve been aware of this new guideline and something doesn’t line up with my experience.
Even with patient education, hard to explain to patient that they probably do NOT need antibiotics
It can be a hard sell in the office. Trying to explain to a patient that they do not need antibiotics
Yes this is the issue. Patients obsessed with the Magic of antibiotics. They will kill their microbiome for no gain. Maybe they should just trust their doctors who are are following very sound evidence-based medicine
I WOULD BE INTERESTED TO KNOW WHY RATES ARE INCREASING. IS IT INCREASED USE OF PROCESSED FOOD.
Approaching this with caution in out-patient setting, I don’t have a CT to rule out complications (15% of cases) like in these studies. Antibiotics could still be indicated to avoid disastrous consequences in the event of undetected complications.
I agree with Will Johnston. 33 years of practice
This article only looks at long term complications but does not look at immediate symptoms ie pain. For my patients (and myself) with the acute pain of diverticulitis I think that the use of antibiotics makes all the difference in the world.
Excellent
Good to know but I agree with Will Johnston
Hard sell in primary care, but may be more applicable to the ER with access to CT.
Agree. My experience of 35 years is that people feel better quite quickly. I don’t buy this.