Patients with mild acute diverticulitis can be safely treated without antibiotics in outpatient setting

Patients who presented to an ED and were randomized to receive only anti-inflammatory and symptomatic treatment had similar rates of hospitalization, return to the ED, and pain control as those who received the usual antibiotic treatment, a Spanish trial found.

Many patients with mild acute diverticulitis can be safely treated out of the hospital without antibiotics, a recent study found.

The open-label trial was conducted in 15 hospitals in Spain. It included 480 patients seen in the ED with symptoms compatible with acute diverticulitis, diagnosed by CT and judged to be mild. They were randomized to either usual treatment (875 mg of amoxicillin and 125 mg of clavulanic acid every eight hours along with anti-inflammatory and symptomatic treatment) or the experimental intervention of only anti-inflammatory and symptomatic treatment. The primary end point was hospital admission and secondary end points included ED revisits, pain control, and emergency surgery. Results were published in the November issue of Annals of Surgery.

In the group receiving usual antibiotics, 14 of 238 (5.8%) patients were hospitalized, compared to eight of 242 (3.3%) patients in the no-antibiotics group, meeting the study's criteria for noninferiority of the experimental intervention. Rates of return to the ED and poor pain control were also similar in the two groups, at 6.7% versus 7.0% and 5.7% versus 2.3%, respectively. None of the patients in either group required emergency surgery. “The results of our outpatient treatment regimen show that it is a safe and effective option,” said the study authors, who noted that two previous trials had shown that treating patients with mild diverticulitis without antibiotics was safe in an inpatient setting.

The main limitation of the study is the significant number of patients who were excluded, the authors said. Exclusion criteria included an acute diverticulitis episode in the last three months, any antibiotic treatment in the last two weeks, significant comorbidities, and poor symptom control in the ED, among other factors.

The study's results should make this the standard of care for such patients, according to its authors and an accompanying commentary. “With mounting evidence that uncomplicated diverticulitis can be safely treated without antibiotics, why are we still using them in North America? The answer is multifactorial and parallels previous struggles to invert widely held medical beliefs on antibiotics,” said the commentary. Contributors to the problem may include clinician unawareness of the latest literature, patient expectations of antibiotics, and skepticism of European trials, the commentary author suggested.