BACKGROUND: In most cases of diverticulitis, inflammation is mild, and the only treatment required is a clear liquid diet and antibiotics. Until recently, patients were given this treatment as inpatients with the consequent expenditure of resources. The aim of this study was to assess the safety and efficacy of an outpatient treatment protocol with oral antibiotics in selected patients with uncomplicated acute diverticulitis in comparison with inpatient intravenous treatment.
METHODS: We conducted a prospective non-randomized study between January 2007 and December 2009. We included all patients diagnosed with uncomplicated acute diverticulitis, at the Emergency Department of the University General Hospital of Elche. We compared the efficacy, safety and costs of hospital treatment with intravenous antibiotics and outpatient treatment with oral antibiotics. Seventy-six patients were included in the study. Forty-four of them underwent intravenous treatment with Metronidazole 500 mg/8 h + Ciprofloxacin 400 mg/12 h (hospital treatment group) and 32 took oral antibiotics Metronidazole 500 mg/8 h and Ciprofloxacin 500 mg/12 h (outpatient group).
RESULTS: Outpatient treatment is viable in almost 95 % of those patients suffering from uncomplicated acute diverticulitis. Treatment was effective in resolving inflammation, and there were no complications in the majority of cases (94 %). Only 2 patients (6 %) required admission after outpatient treatment. The results further reflect complications and relapse rates similar to those of patients admitted to hospital and treated with intravenous antibiotics. There are no significant statistical differences (p = 0.86) between inpatients and outpatients. It is possible to save approximately 1,600 € per patient with outpatient treatment (p < 0.05).
CONCLUSIONS: Outpatient treatment has demonstrated a safety and efficiency similar to inpatient treatment, producing an important reduction in expenses and medical resources.
BACKGROUND: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up.
METHODS: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.
RESULTS: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881).
CONCLUSION: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.
AIM: Evidence supporting outpatient treatment with oral antibiotics in patients with uncomplicated diverticulitis is limited. Our aim was to evaluate the safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis.
METHOD: All patients diagnosed with uncomplicated diverticulitis based on abdominal computed tomography findings from June 2003 to December 2008 were considered for outpatient treatment. Admission was indicated in patients not able to tolerate oral intake and those with comorbidity or without adequate family support. Treatment consisted of oral antibiotics for 7 days (amoxicillin-clavulanic or ciprofloxacin plus metronidazole in patients with penicillin allergy). Patients were seen again at between 4 and 7 days after starting treatment to confirm symptom improvement.
RESULTS: Ninety-six patients were diagnosed with uncomplicated acute diverticulitis and 26 presented at least one criterion for admission. Ambulatory treatment was initiated in 70 (73%) patients. Only two (3%) required admission because of persisting abdominal pain and vomiting, respectively. Intravenous antibiotics resolved the inflammatory process in both cases. In the remaining 68 (97%), ambulatory treatment was completed without complication.
CONCLUSION: Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable to most patients with tolerance to oral intake and without severe comorbidity and having appropriate family support.
In uncomplicated diverticular disease, treatment is aimed at relieving symptoms. The aim of the present study was to evaluate the efficacy of mesalazine for symptomatic relief of uncomplicated diverticular disease of the colon. Two hundred sixty-eight consecutive eligible outpatients (122 male, 146 female; age, 66.1 years; range, 31-81 years) were enrolled in four treatment schedules in a randomized fashion: Group R1 (66 patients), rifaximin, 200 mg bid; Group R2 (69 patients), rifaximin, 400 mg bid; Group M1 (67 patients), mesalazine, 400 mg bid; and Group M2 (66 patients), mesalazine, 800 mg bid. Treatments were administered for 10 days every month for 12 months. Clinical evaluations were performed at admission and at 3-month intervals for 12 months considering 12 clinical variables (upper and lower abdominal pain/discomfort, tenesmus, diarrhea, abdominal tenderness, fever, bloating, general illness, nausea, emesis, dysuria, bleeding) graded as 0 = no symptoms, 1 = mild, 2 = moderate, and 3 = severe. The Global Symptomatic Score (GSS) was calculated using the sum of each symptom score. Two hundred forty-four patients completed the 12- month study; 24 were discontinued (14 treated with rifaximin and 10 treated with mesalazine) either as voluntary dropouts or because they developed side effects and/or complications. Group M2 demonstrated a lower frequency of many symptoms after 6 and 12 months of treatment; the mean GSS was significantly lower in Group M2 after 6 and 12 months of therapy by both intention-to-treat and per-protocol analyses. Patients treated with mesalazine (Groups M1+M2) had a lower GSS than subjects treated with rifaximin (Groups R1+R2) during the 12-month follow-up period. We conclude that cyclic administration of mesalazine is effective for symptomatic relief of uncomplicated diverticular disease of the colon. Some symptoms showed greater improvement with mesalazine, 800 mg bid, than with the other treatment schedules.
OBJECTIVE: Most patients admitted for acute colonic diverticulitis (AD) are managed conservatively and receive antibiotics, although it is uncertain whether all patients with AD benefit from this treatment. The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD.
MATERIAL AND METHODS: A retrospective audit of 311 patients (64% F, mean age 60 years) hospitalized for AD was carried out. All patients were initially treated conservatively with observation and restriction of oral intake. Patients receiving antibiotics (n=118) were compared with patients treated with observation and restriction of oral intake only (n=193). Mean follow-up time (FU) was 30 months.
RESULTS: Inflammation in patients treated with antibiotics was more pronounced (laboratory parameters (C-reactive protein, white blood cell count) were higher (p<0.01), fever was more common (p<0.01) and CT grading of inflammation was classified as severe in a higher proportion (p<0.01)) compared with patients treated without antibiotics. When initially treated with antibiotics, 3 patients (3%) failed to respond to treatment and had to undergo surgery. There were 7 (4%) failures in patients initially treated without antibiotics, and antibiotics were then added. During FU, 29% of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) compared with 28% (NS) among those treated without antibiotics. In a multivariate analysis, the risk of a further event was not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61-1.74).
CONCLUSIONS: Our results indicate that antibiotics are not mandatory in mild AD. Treatment without antibiotics appears to be safe and seems not to change the rate of further events. These results warrant further randomized prospective studies.
BACKGROUND: There are no management criteria for optimum out-patient care in mild-to-moderate acute colonic diverticulitis.
AIM: To enable such patients to be managed in an out-patient setting, by establishing criteria and treatment protocols.
METHODS: We conducted an open trial and follow-up study from 1997 to 2002. On the basis of ultrasonography, we defined and categorized mild-to-moderate acute colonic diverticulitis ranging from limited inflammation within diverticulum to an abscess < 2 cm in diameter. Subjects were treated as out-patients and followed a 10-day treatment protocol consisting of an oral antibiotic and a sports drink for the first 3 days. Physical examination and laboratory testing helped determine whether or not a patient could resume a liquid diet on day 4, and a regular diet on day 7.
RESULTS: Of the 70 patients, 68 were successfully treated. Two patients required hospitalization. Of the 65 patients who were tracked over several months [median (intraquarter range) = 30.8 (11.9-44.2) months], 16 had one or more clinical recurrences. The medical cost per episode was 80% lower than in-patient treatment.
CONCLUSIONS: Patients with mild-to-moderate acute colonic diverticulitis can be safely and successfully treated as out-patients using this protocol.
AIM: The main cause of acute diverticulitis is the abnormal accumulation of fecal bacteria within the diverticular lumen, leading to a balancing between normal probiotic microflora and pathogenic species; Gram negative Entero-bacteriaceae, mainly Escherichia coli and Proteus spp, are the genders that usually cause the disease-related symptoms, due to their ability to adhere to intestinal mucosa. The intestine is well known as the largest human lymphoepithelial organ and daily produces more antibodies, mainly secretory IgAs, than do all other lymphoid tissues. IgAs have different immune and anti-inflammatory properties. The aim of this study was to verify the efficacy of an oral immunostimulant highly-purified, polymicrobial lysate in the prevention of recurrent attacks of diverticulitis and in the improvement of symptoms.
METHODS: The study was carried out on 83 consecutive patients suffering from recurrent symptomatic acute diverticulitis and with at least 2 attacks in the previous year; patients were randomly assigned to receive (group A) an oral polybacterial lysate suspension or to a no-treatment clinical follow-up as controls (group B).
RESULTS: A total of 76 patients (41 in group A and 35 in group B) terminated the study period. the sums of the scores for symptoms, reported on day schedules, were calculated and examined by means of ANOVA statistical analysis. Statistical differences between group A vs group B were recorded after 1 month (p<0.05) and 3 months (p<0.01) of treatment with the oral polybacterial lysate suspension.
CONCLUSIONS: Our data suggest that the administration of an oral enterovaccine for the prophylaxis of recurrent diverticulitis is effective and well tolerated, probably due to a direct stimulation of IgA-mediated mucosal defences.
BACKGROUND: Rifaximin plus mesalazine has been showed to be more effective than rifaximin alone in the treatment of recurrent and complicated diverticulitis of the colon. We investigated the effectiveness of the combination rifaximin/mesalazine followed by mesalazine alone to evaluate tolerability and effectiveness in symptomatic remission in uncomplicated diverticular disease.
MATERIAL/METHODS: We studied 90 consecutive patients (39 M, 51 F, mean age 67.2 yrs, range 32-91 yrs) with symptomatic uncomplicated diverticular disease. We assessed the following symptoms, scoring them on a quantitative scale: 1) constipation, 2) diarrhea, 3) abdominal pain, 4) rectal bleeding, and 5) mucus with stools. All were treated with 800 mg/day rifaximin plus 2.4 gr/day mesalazine for 10 days, followed by 1.6 gr/day mesalazine for 8 weeks. They were re-evaluated at the end of mesalazine-alone treatment.
RESULTS: Eighty-six patients completed the study (95.56%): the total score decreased from 1439 to 44 (p<0.001). 70 patients (per-protocol: 81.40% (C.I.: 67-94%); on intention-to-treat: 77.78% (C.I.: 60-85%)) were completely asymptomatic after the 8th week of treatment with mesalazine alone (total symptomatic score: 0), while 16 (per-protocol: 18.60%; on intention-to-treat: 17.77%) showed only slight symptoms (total score: 44). Two (2.22%) showed recurrence of diverticulitis after 4 and 6 weeks of treatment with mesalazine alone. Two patients (2.22%) were withdrawn from the study for diarrhea after starting mesalazine. Two others (2.22%) showed transitory pruritus (one) and epigastric pain (one).
CONCLUSIONS: The results show that rifaximin/mesalazine followed by mesalazine alone is extremely effective in resolving symptoms in patients with symptomatic uncomplicated diverticular disease.
In most cases of diverticulitis, inflammation is mild, and the only treatment required is a clear liquid diet and antibiotics. Until recently, patients were given this treatment as inpatients with the consequent expenditure of resources. The aim of this study was to assess the safety and efficacy of an outpatient treatment protocol with oral antibiotics in selected patients with uncomplicated acute diverticulitis in comparison with inpatient intravenous treatment.
METHODS:
We conducted a prospective non-randomized study between January 2007 and December 2009. We included all patients diagnosed with uncomplicated acute diverticulitis, at the Emergency Department of the University General Hospital of Elche. We compared the efficacy, safety and costs of hospital treatment with intravenous antibiotics and outpatient treatment with oral antibiotics. Seventy-six patients were included in the study. Forty-four of them underwent intravenous treatment with Metronidazole 500 mg/8 h + Ciprofloxacin 400 mg/12 h (hospital treatment group) and 32 took oral antibiotics Metronidazole 500 mg/8 h and Ciprofloxacin 500 mg/12 h (outpatient group).
RESULTS:
Outpatient treatment is viable in almost 95 % of those patients suffering from uncomplicated acute diverticulitis. Treatment was effective in resolving inflammation, and there were no complications in the majority of cases (94 %). Only 2 patients (6 %) required admission after outpatient treatment. The results further reflect complications and relapse rates similar to those of patients admitted to hospital and treated with intravenous antibiotics. There are no significant statistical differences (p = 0.86) between inpatients and outpatients. It is possible to save approximately 1,600 € per patient with outpatient treatment (p < 0.05).
CONCLUSIONS:
Outpatient treatment has demonstrated a safety and efficiency similar to inpatient treatment, producing an important reduction in expenses and medical resources.
