#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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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