PURPOSE: Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics.
METHODS: The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model.
RESULTS: In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469).
CONCLUSIONS: The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.
AIM: The optimal diet for uncomplicated diverticulitis is unclear. Guidelines refrain from recommendation due to lack of objective information. The aim of the study was to determine whether an unrestricted diet during a first acute episode of uncomplicated diverticulitis is safe.
METHOD: A prospective cohort study was performed of patients diagnosed with diverticulitis for the first time between 2012 and 2014. Requirements for inclusion were radiologically proven modified Hinchey Ia/b diverticulitis, American Society of Anesthesiologists class I-III and the ability to tolerate an unrestricted diet. Exclusion criteria were the use of antibiotics and suspicion of inflammatory bowel disease or malignancy. All included patients were advised to take an unrestricted diet. The primary outcome parameter was morbidity. Secondary outcome measures were the development of recurrence and ongoing symptoms.
RESULTS: There were 86 patients including 37 (43.0%) men. All patients were confirmed to have taken an unrestricted diet. There were nine adverse events in seven patients. These consisted of readmission for pain (five), recurrent diverticulitis (one) and surgery (three) for ongoing symptoms (two) and Hinchey Stage III (one). Seventeen (19.8%) patients experienced continuing symptoms 6 months after the initial episode and 4 (4.7%) experienced recurrent diverticulitis.
CONCLUSION: The incidence of complications among patients taking an unrestricted diet during an initial acute uncomplicated episode of diverticulitis was in line with that reported in the literature.
INTRODUCTION: Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management.
OBJECTIVE: To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD.
MATERIAL AND METHODS: Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery.
RESULTS: The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage.
CONCLUSIONS: The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD.
PURPOSE: Antibiotic treatment is the treatment of choice for uncomplicated diverticulitis (uD) and can be performed for mild complicated diverticulitis (mcD). In several cases, outpatient treatment (OT) can be undertaken. This study assessed the 1-month failure rate of OT for uD/mcD compared to inpatient treatment (IT), and identified predictive factors for treatment failure.
METHODS: All consecutive patients (2006-2012) diagnosed with uD/mcD by CT scan were retrospectively analyzed. Acute uD was defined as absence of the following: abscess, fistula, extraluminal contrast, pneumoperitoneum, and need for immediate percutaneous drainage/surgery. Acute mcD was defined as complicated diverticulitis with abscess <4 cm or pneumoperitoneum <2 cm. All patients received antibiotherapy. Treatment failure was defined as (re)hospitalization the first month after treatment onset or need of drainage/surgery during hospitalization. All patients were contacted using a standardized questionnaire.
RESULTS: Out of 540 uD/mcD, IT was offered to 369 patients (68%) and OT to 171 patients (32%). The IT group had higher median age, more women, higher median Charlson Index, more severe median Ambrosetti score, longer median time in the emergency room, and higher median CRP. Response rates to the questionnaire were 56% (IT) vs. 62% (OT), p = 0.18. Failure rates were 32% in IT vs. 10% in OT group, p < 0.01. Among the uD/mcD patients, admission/CT time between midnight and 6 AM, Ambrosetti score of 4, and free air around the colon were risk factors for failure.
CONCLUSIONS: Outpatient treatment for uncomplicated/mild complicated diverticulitis is feasible and safe. Prognostic factors of failure necessitating closer follow-up were admission/CT time, Ambrosetti score of 4, and free air around the colon.
BACKGROUND: Inpatient treatment of patients with colon diverticulitis represents a significant financial and clinical burden to the health care system and patients. The aim of this study was to compare patients with diverticulitis in the emergency department (ED), who were discharged to home vs admitted to the hospital.
STUDY DESIGN: We reviewed all patients evaluated in the ED of a metropolitan health system, with the primary diagnosis of diverticulitis (ICD-9 562.11), from 2010 through 2012. Only patients diagnosed with CT and those with follow-up were included.
RESULTS: We identified 240 patients; 132 (55%) were women and mean age was 59.1 years (SD 16.1 years). Imaging findings included extraluminal air (21%), pericolic or pelvic abscess (12%), free fluid (16%), and pneumoperitoneum (6%). One hundred forty-four (60%) were admitted to the hospital and 96 (40%) were discharged to home on oral antibiotics. Patients admitted to the hospital were more likely to be older than 65 years (p = 0.0007), have a Charlson comorbidity score ≥ 2 (p = 0.0025), to be on steroids or immunosuppression (p = 0.0019), and have extraluminal air (p < 0.0001) or diverticular abscess (p < 0.0001) on imaging. Median follow-up for all patients was 36.5 months (interquartile range 25.2 to 43 months). Among patients discharged from the ED, 12.5% returned to the ED or were readmitted within 30 days, with only 1 patient (1%) requiring emergency surgery, but not until 20 months later. Patients admitted to the hospital had similar rates of readmission (15%; p = 0.65).
CONCLUSIONS: Patients diagnosed with uncomplicated diverticulitis in the emergency room can be safely discharged home on oral antibiotics, as long as CT findings are included in the decision-making process. Patients with complicated diverticulitis on CT scan should be admitted to the hospital with surgical consultation.
Background: Antibiotics are advised in most guidelines on acute diverticulitis, despite a lack of evidence to support their routine use. This trial compared the effectiveness of a strategy with or without antibiotics for a first episode of uncomplicated acute diverticulitis. Methods: Patients with CT-proven, primary, left-sided, uncomplicated, acute diverticulitis were included at 22 clinical sites in the Netherlands, and assigned randomly to an observational or antibiotic treatment strategy. The primary endpoint was time to recovery during 6 months of follow-up. Main secondary endpoints were readmission rate, complicated, ongoing and recurrent diverticulitis, sigmoid resection and mortality. Intention-to-treat and per-protocol analyses were done. Results: A total of 528 patients were included. Median time to recovery was 14 (i.q.r. 6–35) days for the observational and 12 (7–30) days for the antibiotic treatment strategy, with a hazard ratio for recovery of 0·91 (lower limit of 1-sided 95 per cent c.i. 0·78; P = 0·151). No significant differences between the observation and antibiotic treatment groups were found for secondary endpoints: complicated diverticulitis (3·8 versus 2·6 per cent respectively; P = 0·377), ongoing diverticulitis (7·3 versus 4·1 per cent; P = 0·183), recurrent diverticulitis (3·4 versus 3·0 per cent; P = 0·494), sigmoid resection (3·8 versus 2·3 per cent; P = 0·323), readmission (17·6 versus 12·0 per cent; P = 0·148), adverse events (48·5 versus 54·5 per cent; P = 0·221) and mortality (1·1 versus 0·4 per cent; P = 0·432). Hospital stay was significantly shorter in the observation group (2 versus 3 days; P = 0·006). Per-protocol analyses were concordant with the intention-to-treat analyses. Conclusion: Observational treatment without antibiotics did not prolong recovery and can be considered appropriate in patients with uncomplicated diverticulitis. Registration number: NCT01111253 (http://www.clinicaltrials.gov).
AIM: This study aimed to evaluate the implementation of nonantibiotic management of acute uncomplicated diverticulitis at a large university hospital in Norway with regard to management failure, disease recurrence and complications.
METHOD: On 1 January 2013 we implemented a new policy for the management of acute uncomplicated diverticulitis without antibiotics. Antibiotic treatment was only provided in the case of defined criteria. All patients admitted from 1 January 2013 to 30 June 2014 with a CT-verified, left-sided, acute uncomplicated diverticulitis were included in the study and evaluated retrospectively, with 12 months' follow-up.
RESULTS: Of 244 admissions with acute uncomplicated diverticulitis, 177 (73%) were managed without antibiotics. Among these there were seven (4%) management failures, including five patients in whom a deteriorating clinical picture prompted antibiotic treatment and two readmissions within 1 month due to persisting symptoms. The only complication in this group was one fistula (< 1%). Eight (5%) patients had a recurrence of acute diverticulitis requiring hospital care and two (1%) underwent elective surgery within the first year. Twenty (8%) patients met predefined exemption criteria and received antibiotics from admission, six (30%) of whom developed complications. The recurrence rate in this group was 10% and none had surgery performed. The 47 (20%) policy violators treated with antibiotics from admission had no complications. Their recurrence rate was 11% and one (2%) patient underwent elective surgery.
CONCLUSION: This study confirms that nonantibiotic management of acute uncomplicated diverticulitis is safe and feasible. Most complications occurred in a small group of high-risk patients treated with antibiotics.
BACKGROUND: Even though evidence for nonantibiotic treatment of uncomplicated diverticulitis exists, it has not gained widespread adoption. OBJECTIVE: The aim of this prospective single-arm study was to analyze the safety and efficacy of symptomatic (nonantibiotic) treatment for uncomplicated diverticulitis during a 30-day follow-up period. DESIGN: This study is a single-arm prospective trial (ClinicalTrials.gov ID NCT02219698). SETTINGS: This study was performed at an academic teaching hospital functioning as both a tertiary and secondary care referral center. PATIENTS: Patients, who had CT-verified uncomplicated acute colonic diverticulitis (including diverticulitis with pericolic air), were evaluated for the study. Patients with ongoing antibiotic therapy, immunosuppression, suspicion of peritonitis, organ dysfunction, pregnancy, or other infections requiring antibiotics were excluded. INTERVENTIONS: Symptomatic in-or outpatient treatment consisted of mild analgesics (nonsteroidal anti-inflammatory drug or paracetamol). MAIN OUTCOME MEASURES: The incidence of complicated diverticulitis was the primary outcome. RESULTS: Overall, 161 patients were included in the study, and 153 (95%) completed the 30-day follow-up. Four (3%) of these patients were misdiagnosed (abscess in the initial CT scan). A total of 14 (9%) patients had pericolic air. Altogether, 140 (87%) patients were treated as outpatients, and 4 (3%) of them were admitted to the hospital during the follow-up. None of the patients developed complicated diverticulitis or required surgery, but, 2 days (median) after inclusion, antibiotics were given to 14 (9%, 6 orally, 8 intravenously) patients. LIMITATIONS: This study is limited by the lack of a comparison group and by the relatively short follow-up. CONCLUSIONS: Symptomatic treatment of uncomplicated diverticulitis without antibiotics is safe and effective.
BACKGROUND/AIMS: Most cases of diverticular inflammation are mild and require only medical treatment with liquid diet and antibiotics. Until recently, this treatment required admission to hospitals, which consequently entailed costs. In most cases, treatment was conservative, and less than a quarter of patients admitted actually underwent surgery. In the last year, the outpatient treatment of these patients with uncomplicated diverticulitis has proven effective and safe. The aim of the present study was to describe our experience after 5 years of outpatient treatment with oral antibiotics.
MATERIALS AND METHODS: We conducted a retrospective revision study between January 2010 and December 2014. We included all patients admitted to the Emergency Department of the University General Hospital of Elche with a diagnosis of uncomplicated acute diverticulitis based on medical history, physical examination and abdominopelvic computed tomography (CT) scanning. Outpatient treatment consisted of oral antibiotics for 10 days (metronidazole 500 mg/8 h and ciprofloxacin 500 mg/12 h), a liquid diet and oral analgesics (acetaminophen 1 g/6 h).
RESULTS: During the period from January 2010 to December 2014, 224 patients were treated on an outpatient basis at a success rate of over 92%. Only 18 patients (8%) required admission after outpatient treatment.
CONCLUSION: Outpatient treatment of uncomplicated acute diverticulitis was demonstrated to be safe and effective.
BACKGROUND: A growing body of knowledge is calling into question the use of antibiotics in acute diverticulitis (AD). Moreover, recent studies provide evidence regarding the security of treating patients with AD as outpatients. The aim of this study was to evaluate a restrictive antibiotic outpatient protocol for the treatment of mild-to-moderate episodes of AD.
METHODS: All patients with symptoms of AD presenting to our emergency department were assigned a modified Neff stage. Patients with mild AD received outpatient treatment without antibiotics. Patients with mild AD and comorbidities were admitted to receive the same treatment. Patients with moderate AD were admitted for 48 h and were then managed as outpatients until they had completed 10 days of antibiotic treatment.
RESULTS: Between April 2013 and November 2014, we attended 110 patients with a diagnosis of AD, 77 of whom we included in the study: 45 patients with mild AD and 32 with moderate AD. Of the patients with mild AD, 88.8 % successfully completed the non-antibiotic, non-admission treatment regime and 95.5 % benefited from a non-antibiotic regime, whether as outpatients or inpatients. A total of 88 % of patients with mild AD and 87.5 % of patients with moderate AD who met the inclusion criteria completed treatment as outpatients without incident. No major complications (abscess, emergency surgery) or deaths were recorded.
CONCLUSIONS: Outpatient treatment without antibiotics for patients with mild AD is safe and effective. Patients with moderate AD can be safely treated with antibiotics in a mixed regime as inpatients and outpatients.
Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics.
METHODS:
The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model.
RESULTS:
In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469).
CONCLUSIONS:
The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.
