BACKGROUND: Despite low-quality and conflicting evidence, the Association of Coloproctology of Great Britain and Ireland recommends the routine use of antibiotics in the treatment of uncomplicated acute diverticulitis. Recent studies have shown that treatment without antibiotics did not prolong recovery. Some new guidelines currently recommend selective use of antibiotics.
OBJECTIVE: The purpose of this study was to compare the safety, effectiveness, and outcomes in treating uncomplicated acute diverticulitis without antibiotics with treatment with antibiotics.
DATA SOURCES: PubMed, Embase, Clinicaltrials.gov, and the Cochrane Library were searched with the key words antibiotics and diverticulitis.
STUDY SELECTION: All studies published in English on treating uncomplicated acute diverticulitis without antibiotics and containing >20 individuals were included.
INTERVENTION: Treatment without antibiotics versus treatment with antibiotics were compared.
MAIN OUTCOME MEASURES: The primary outcome was the percentage of patients requiring additional treatment or intervention to settle during the initial episode. The secondary outcomes were duration of hospital stay, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, and complication.
RESULTS: Search yielded 1164 studies. Nine studies were eligible and included in the meta-analysis, composed of 2505 patients, including 1663 treated without antibiotics and 842 treated with an antibiotic. The no-antibiotics group had a significantly shorter hospital stay (mean difference = -0.68; p = 0.04). There was no significant difference in the percentage of patients requiring additional treatment or intervention to settle during the initial episode (5.3% vs 3.6%; risk ratio = 1.48; p = 0.28), rate of readmission or deferred admission (risk ratio = 1.17; p = 0.26), need for surgical or radiological intervention (risk ratio = 0.61; p = 0.34), recurrence (risk ratio = 0.83; p = 0.21), and complications (risk ratio = 0.70-1.18; p = 0.67-0.91).
LIMITATIONS: Only a limited number of studies were available, and they were of variable qualities.
CONCLUSIONS: Treatment of uncomplicated acute diverticulitis without antibiotics is associated with a significantly shorter hospital stay. There is no significant difference in the percentage of patients requiring additional treatment or intervention to settle in the initial episode, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, or complications.
BACKGROUND: In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting.
METHODS: A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment.
RESULTS: This systematic review included 21 studies including 1781 patients who had outpatient management of AD including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data.
CONCLUSIONS: The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.
BACKGROUND: Antibiotics use in acute uncomplicated diverticulitis (AUD) remains debated despite recent studies suggesting no difference in outcomes for patients treated without antibiotics.
DATA SOURCES: Systematic review and meta-analysis were performed to determine the role of antibiotics in managing AUD. Literature search was conducted using Medline, EMBASE, Scopus, the Cochrane Library, and Web of Science databases from 1946 to June 2017. Eight studies with 2469 patients were included for review. Overall complication rates were not statistically significant between groups (OR 0.72; CI 0.45 to 1.16; P = 0.18), but antibiotic use was associated with a longer length of stay in hospital. Subgroup analysis revealed no difference in readmission rates, treatment failure rates, progression to complicated diverticulitis, or increased need for elective or emergent surgery between study groups.
CONCLUSIONS: Antibiotic use in patients with AUD increases length of hospital stay but is not associated with a reduction in overall or individual complication rates.
BACKGROUND: Diverticulitis is a common complication of diverticular disease of the colon. While complicated diverticulitis often warrants intervention, acute uncomplicated diverticulitis (AUD) is usually managed conservatively. The aim of the present review was to evaluate the efficacy and safety of conservative treatment of AUD without antibiotics compared to standard antibiotic treatment.
METHODS: A systematic literature review in compliance with PRISMA guidelines was conducted. Electronic databases including PubMed/Medline, Scopus, Embase and Cochrane central register of controlled trials were searched. Studies that assessed efficacy and safety of treatment of AUD without antibiotics were included. Outcome parameters were rates of treatment failure, recurrence of diverticulitis, complications and mortality, readmission to hospital, and need for surgery.
RESULTS: Nine studies including 2565 patients were included to the review. Of these patients, 65.1% were treated conservatively without antibiotics. Treatment failure was observed in 5.1% of patients not-given-antibiotic treatment versus 3.4% of those given antibiotic treatment. Recurrent diverticulitis occurred in 9.3% of patients in the non-antibiotic group versus 12.1% of patients in the antibiotic group. On meta-analysis of the studies, there were no significant differences between non-antibiotic and antibiotic treatment groups regarding rates of treatment failure (OR = 1.5, p = 0.06), recurrence of diverticulitis (OR = 0.81, p = 0.2), complications (OR = 0.56, p = 0.25), readmission rates (OR = 0.97, p = 0.91), need for surgery (OR = 0.59, p = 0.28), and mortality (OR = 0.64, p = 0.47). The only variable that was significantly associated with treatment failure in the non-antibiotic treatment group was associated comorbidities (standard error (SE) = - 0.07, 95% CI - 0.117 - 0.032; p < 0.001).
CONCLUSIONS: Treatment of AUD without antibiotics is feasible, safe, and effective. Adding broad-spectrum antibiotics to the treatment regimen did not serve to decrease treatment failure, recurrence, complications, hospital readmissions, and need for surgery significantly compared to non-antibiotic treatment.
BACKGROUND: Acute diverticulitis occurs in 25% of individuals with diverticular disease and is associated with significant morbidity and mortality rates. Disease severity is classified as uncomplicated or complicated, with the latter including perforation, fistula, obstruction, or distant abscess. Uncomplicated diverticulitis often improves without surgery or invasive therapies. Administration of antibiotics is a standard of care for treatment of acute uncomplicated diverticulitis. However, recent data suggest antibiotics do not influence outcomes significantly. To address these conflicting approaches, the Surgical Infection Society hosted an Update Symposium at its 37th Annual Meeting examining the role of antibiotics in the treatment of acute uncomplicated diverticulitis. Here, we provide a synopsis of the symposium's findings and a brief review of recent prospective and randomized clinical trials on the topic.
METHODS: A search of Embase, MEDLINE, and the Cochrane Library was performed for prospective series and randomized clinical trials published between January 1, 2010, and January 1, 2018, comparing outcomes of antibiotic versus no antibiotic therapy for acute uncomplicated diverticulitis.
RESULTS: We identified two single-center prospective series and two randomized clinical trials comparing outcomes for patients with acute uncomplicated diverticulitis treated with antibiotics versus no antibiotics.
CONCLUSION: Current evidence does not support administration of antibiotics to improve outcomes in carefully selected healthy patients with acute uncomplicated left-sided diverticulitis. Further studies should help identify specific subpopulations of patients who would derive benefit from antibiotic therapy and help define appropriate antibiotic regimens and treatment durations that minimize cost, adverse effects, and risk of anti-microbial resistance.
BACKGROUND: The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world.
PURPOSE: Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.
METHODS: PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.
RESULTS: A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I
CONCLUSION: Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.
BACKGROUND: Acute uncomplicated diverticulitis (AUD) is common and antibiotics are the cornerstone of traditional conservative management. This approach lacks clear evidence base and studies have recently suggested that avoidance of antibiotics is a safe and efficacious way to manage AUD. The aim of this systematic review is to determine the safety and efficacy of treating AUD without antibiotics.
METHODS: A systematic search of Embase, Cochrane library, MEDLINE, Science Citation Index Expanded, and ClinicalTrials. gov was performed. Studies comparing antibiotics versus no antibiotics in the treatment of AUD were included. Meta-analysis was performed using the random effects model with the primary outcome measure being diverticulitis-associated complications. Secondary outcomes were readmission rate, diverticulitis recurrence, mean hospital stay, requirement for surgery and requirement for percutaneous drainage.
RESULTS: Eight studies were included involving 2469 patients; 1626 in the non-antibiotic group (NAb) and 843 in the antibiotic group (Ab). There was a higher complication rate in the Ab group however this was not significant (1.9% versus 2.6%) with a combined risk ratio (RR) of 0.63 (95% CI, 0.25 to 1.57, p=0.32). There was a shorter mean length of hospital stay in the Nab group (standard mean difference of -1.18 (95% CI, -2.34 to -0.03 p= 0.04). There was no significant difference in readmission, recurrence and surgical intervention rate or requirement for percutaneous drainage.
CONCLUSION: Treatment of AUD without antibiotics may be feasible with outcomes that are comparable to antibiotic treatment and with potential benefits for patients and the NHS. Large scale randomised multicentre studies are needed. This article is protected by copyright. All rights reserved.
Despite low-quality and conflicting evidence, the Association of Coloproctology of Great Britain and Ireland recommends the routine use of antibiotics in the treatment of uncomplicated acute diverticulitis. Recent studies have shown that treatment without antibiotics did not prolong recovery. Some new guidelines currently recommend selective use of antibiotics.
OBJECTIVE:
The purpose of this study was to compare the safety, effectiveness, and outcomes in treating uncomplicated acute diverticulitis without antibiotics with treatment with antibiotics.
DATA SOURCES:
PubMed, Embase, Clinicaltrials.gov, and the Cochrane Library were searched with the key words antibiotics and diverticulitis.
STUDY SELECTION:
All studies published in English on treating uncomplicated acute diverticulitis without antibiotics and containing >20 individuals were included.
INTERVENTION:
Treatment without antibiotics versus treatment with antibiotics were compared.
MAIN OUTCOME MEASURES:
The primary outcome was the percentage of patients requiring additional treatment or intervention to settle during the initial episode. The secondary outcomes were duration of hospital stay, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, and complication.
RESULTS:
Search yielded 1164 studies. Nine studies were eligible and included in the meta-analysis, composed of 2505 patients, including 1663 treated without antibiotics and 842 treated with an antibiotic. The no-antibiotics group had a significantly shorter hospital stay (mean difference = -0.68; p = 0.04). There was no significant difference in the percentage of patients requiring additional treatment or intervention to settle during the initial episode (5.3% vs 3.6%; risk ratio = 1.48; p = 0.28), rate of readmission or deferred admission (risk ratio = 1.17; p = 0.26), need for surgical or radiological intervention (risk ratio = 0.61; p = 0.34), recurrence (risk ratio = 0.83; p = 0.21), and complications (risk ratio = 0.70-1.18; p = 0.67-0.91).
LIMITATIONS:
Only a limited number of studies were available, and they were of variable qualities.
CONCLUSIONS:
Treatment of uncomplicated acute diverticulitis without antibiotics is associated with a significantly shorter hospital stay. There is no significant difference in the percentage of patients requiring additional treatment or intervention to settle in the initial episode, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, or complications.
