Outpatient Management of Acute Sigmoid Diverticulitis: Education and a Clinical Pathway Reduced Antibiotic Use Without Compromise in Clinical Outcomes.

Objective Standard treatment for uncomplicated diverticulitis in our institution consists of antibiotics. However, current evidence suggests that bacterial infection has a less predominant role than previously thought, and that uncomplicated acute diverticulitis may be a self-limiting condition in which inflammation can be managed without antibiotics. With the support of a multidisciplinary team we developed an intervention in order to reduce the use of antibiotics for patients with uncomplicated diverticular disease. Methods Standard practice and knowledge of current evidence were investigated with a structured survey sent to general practitioners and gastroenterologists with private practice in the area. A clinical process model for treatment of uncomplicated left-sided diverticulitis was created and exclusion criteria were selected in order to define patients with a high risk of developing complications. An educational intervention based on current evidence and the new treatment pathway was conducted on hospital staff as well as primary care physicians in the area in order to raise awareness about the possibility of avoiding antibiotics in uncomplicated diverticulitis. Patients were also involved and received an informative sheet about the rationale of the new treatment, the planned follow up and warning signs warranting further investigations and referral in case of outpatient treatment. All patients from May 2021 to December 2021 with a computed tomography-verified left-sided acute uncomplicated diverticulitis were included in the study and evaluated prospectively. Results Of 60 patients with acute uncomplicated diverticulitis, 23 (38%) were eligible for treatment without antibiotics. High inflammatory markers on presentation were the main reason (84%) for giving antibiotics. Adherence to the new policy was 74%. None of the 17 patients initially managed without antibiotics failed conservative treatment. Conclusion This project confirmed that treatment of uncomplicated diverticulitis without antibiotics can successfully be offered to a selected group of patients without altering the course of the disease. Further efforts are needed in order to overcome existing barriers to rational antimicrobial use such as lack of trust in new guidelines, general uncertainty and risk avoidance, patients’ expectations for antibiotic treatment, and fear of legal consequences.

The value of antibiotics in the treatment of acute uncomplicated left-sided diverticulitis is not well established. The aim of this review was to assess whether or not antibiotics contribute to the (uneventful) recovery from acute uncomplicated left-sided diverticulitis, and which types of antibiotic and route of administration are most effective. Medline, the Cochrane Library and Embase databases were searched. Randomized controlled trials (RCTs), prospective or retrospective cohort studies addressing conservative treatment of mild uncomplicated left-sided diverticulitis and use of antibiotics were included. No randomized or prospective studies were found on the topic of effect on outcome. One retrospective cohort study was retrieved that compared a group treated with antibiotics with observation alone. This study showed no difference in success rate between groups. Only one RCT of moderate quality compared intravenous and oral administration of antibiotics, and found no differences. One other RCT of very poor quality compared two different kinds of intravenous antibiotic and also found no difference. A small retrospective cohort study comparing antibiotics with and without anaerobe coverage showed no difference in group outcomes. Evidence on the use of antibiotics in mild or uncomplicated diverticulitis is sparse and of low quality. There is no evidence mandating the routine use of antibiotics in uncomplicated diverticulitis, although several guidelines recommend this. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Colorectal cancer (CRC) can mimic acute diverticulitis and can thus be misdiagnosed. Therefore, colonic evaluation is recommended after an episode of acute diverticulitis. The aim of this study was to analyze the risk of CRC after computed tomography (CT) verified uncomplicated and complicated acute diverticulitis in short-term and, particularly, long-term follow-up to ensure the feasibility of the primary CT imaging in separating patients with uncomplicated and complicated acute diverticulitis. A retrospective cohort study was conducted in patients with CT-verified acute diverticulitis in 2003-2012. Data on CT findings and colonic evaluations were analyzed. The patients were divided into those with uncomplicated and complicated acute diverticulitis. Patient charts were reviewed 9-18 years after the initial acute diverticulitis episode. The study population consisted of 270 patients. According to CT scans, 170 (63%) patients had uncomplicated acute diverticulitis and 100 (37%) had complicated acute diverticulitis. Further colonic evaluation was made in 146 (54%) patients. In the whole study population, CRC was found in 7 (2.6%) patients, but CRC was associated with acute diverticulitis in only 4 (1.5%) patients. The short-term risk for CRC was 0.6% (1/170) in uncomplicated acute diverticulitis and 3.0% (3/100) in complicated acute diverticulitis. No additional CRC was found in patients with complicated acute diverticulitis during the long-term follow-up and three cases of CRC found after uncomplicated acute diverticulitis had no observable association with previous diverticulitis. In short-term follow-up, the risk of underlying CRC is very low in CT-verified uncomplicated acute diverticulitis but increased in complicated acute diverticulitis. Long-term follow-up revealed no additional CRCs associated with previous acute diverticulitis, indicating that the short-term results remain consistent also in the long run. These long-term results confirm that colonoscopy should be reserved for patients with complicated acute diverticulitis or with persisting or alarming symptoms.

See Article on Page 52-56 Among the wide spectrum of acute diverticulitis, uncomplicated diverticulitis (UD) is defined as a localized inflammation or phlegmon of colonic diverticula in the absence of complications such as abscess, perforation, fistula, obstruction, and bleeding. Acute diverticulitis calls for a differentiated approach to various stages of the disease process. According to guidelines from a related international academic society, the use of antibiotics, either intravenous or oral, is the nub of management in patients with UD. Recently, evidence has accumulated that the majority of these patients successfully respond to outpatient management or oral antibiotic use [1]. Outpatient management of patients with UD is also less expensive for the health care system. A randomized controlled trial from Sweden found that antibiotic use for the treatment of UD neither accelerated recovery nor prevented complications or recurrence [2]. Scarpa et al. [3] have compared the treatment outcomes for patients with UD for different routes of antibiotic administration. Patients were divided into two groups: one received antibiotics entirely via an intravenous route while the other received antibiotics via an intravenous + oral route. According to the investigators, the use of intravenous antibiotics for less than five days did not increase the recurrence of uncomplicated colonic diverticulitis. This finding indicates that patients might be able to avoid an unnecessary admission. However, as the authors mentioned, regardless of the route, intravenous or intravenous + oral, all patients received antibiotics for the same period. Therefore, huge room for investigations on the use of antibiotics still exists. In 2014, The American Society of Colon and Rectal Surgeons revised its statement about 'Practice parameters for sigmoid diverticulitis' that was previously published in 2007 [4]. The most remarkable difference about UD management between the 2007 and the 2014 versions is the introduction of oral antibiotic use as an initial treatment for clinically-stable patients with UD. That the newly emerging trend for UD management is moving to an outpatient setting is becoming more and more obvious. The key to treatment success depends very much on an accurate diagnosis of the stage of acute diverticulitis. The diagnosis of diverticular disease can be made by using a variety of tests, and the accuracy of imaging studies greatly affects the outcome of treatment for UD. Nowadays, computed tomography (CT) scanning is the most appropriate imaging modality to confirm suspected diverticulitis. However, the accuracy of predicting Hinchey classification by using CT scanning is not very high. Gielens et al. [5] reported in their study that the sensitivity and the specificity of CT scans for Hinchey 1 patients were 76%, and 86%, respectively. Even in 42% of the cases, Hinchey 3 perforated diverticulitis was falsely classified as Hinchey 1 or 2. Therefore, before starting the use of antibiotics, a decision making process should be discreetly and conservatively set up to prevent treatment failure. In future studies, investigators should focus on the area of accurate diagnosis of patients for current treatment options. Overall, we may certainly infer that a lesser aggressive treatment seems to be possible for the management of selected patients with UD. However, a considerable number of open questions still remain: for example, the efficacy of treatment with oral antibiotics only, the adequate duration of antibiotic treatment, the feasibility of not using antibiotics, and the role of probiotics and/or anti-inflammatory drugs. Further randomized clinical trials to establish an optimal strategy for treating uncomplicated colonic diverticulitis are encouraged.

Aim Acute diverticulitis is one of the most common gastrointestinal diseases in the Western world. The aim of this audit is to evaluate the management of acute uncomplicated colonic diverticulitis as per the 2020 update of WSES guidelines:Clinical assessment, inflammatory markers, and CT AP in all suspected patientsAntibiotic therapy not recommended in immunocompetent patientsAmbulatory management for immunocompetent patientsRe-evaluation within 7 daysRoutine colonic evaluation is not recommended. Method Data collection proforma designed according to WSES guidelines Retrospective data collection: Acute admissions between July to September 2023 in a single centre Any age and gender CT proven acute uncomplicated diverticulitis Patients with complicated diverticulitis were excluded Results 53 patients were included. Mean Age: 63, Age range: 34 – 89, and 70% patients were female. Commonest CT finding: Sigmoid diverticulitis (n=33).Complete clinical assessment as per guidelinesAll patients, regardless of their clinical status, received antibiotic therapyAmbulatory care offered to only 57% of patientsOnly a small percentage of patients were offered re-evaluation within 7 days (37% compliance)Patients were offered OP colonic evaluation (75% compliance) Conclusions Inconsistent compliance with WSES guidelines for management of acute uncomplicated colonic diverticulitis. Arrange teaching sessions for the surgical staff and devise a management plan for acute uncomplicated diverticulitis that is in accordance with the guidelines. Printouts of WSES guidelines to be made available on the acute surgical floor. Re-audit after 4 – 8 weeks.

Introduction: Acute diverticulitis represents a significant disease burden in the United States and developed world. This article examines current trends in the treatment of acute diverticulitis and concentrates on the utility of antibiotics in acute uncomplicated cases managed in the outpatient setting. Methods: The literature was reviewed for randomized controlled trials (RCTs) to discern the best practice and recommendations for antibiotics for diverticulitis. The time period included relevant RCTs after 2000. Results: Four recent RCTs examine the use of antibiotics in acute uncomplicated diverticulitis. The AVOD study was an RCT that managed inpatients with either antibiotics or IV fluids alone and demonstrated non-inferiority of non-antibiotic management with respect to recovery, complication rates, or recurrence. The DIABLO trial randomized first episodes of acute uncomplicated diverticulitis admitted to the hospital with antibiotics or supportive care and found no difference in morbidity or mortality between the two groups and longer hospital stay for patients treated with antibiotics. The DINAMO study examined outpatients managed with antibiotics by mouth or without and found no difference in morbidity in 90 day follow-up. The STAND study was the only of these four to use a placebo and found no difference between hospital stay or other adverse events at 30 days. In response to this, the ASCRS, AAFP and other societies now recommend against the routine use of antibiotics in acute uncomplicated diverticulitis. Conclusions: Several quality studies found similar outcomes in cases of acute uncomplicated diverticulitis treated with or without antibiotics. Based on these findings, societal guidelines do not recommend routine antibiotics for acute diverticulitis.

Introduction: Diverticulitis is a disease traditionally presumed to be caused by infection and inflammation of colonic diverticula. Although this has been the historical definition, recent evidence suggest an inflammatory rather than infectious etiology. Several studies have shown no benefit in the use of antibiotics versus observation, however, antibiotics continue to be the mainstay of treatment. Imaging studies and laboratory tests are limited in the ability to differentiate between infection and inflammation. Procalcitonin (PCT) is a peptide released from numerous tissue, including the colon in the presence of bacterial infection and systemic inflammation. Under physiologic conditions, levels do not exceed 0.1 ng/ml. Several studies have examined the role of PCT involving intra-abdominal infections, however, there is lack of data regarding the usefulness in patients with acute uncomplicated diverticulitis. Methods: The study was approved by the IRB at St. John Providence hospital in Southfield, Michigan and all participants provided written consent. This study is a prospective cohort clinical trial involving patients presenting to the hospital with acute diverticulitis confirmed by CT scan of the abdomen. Patients were separated into two groups, categorized as uncomplicated or complicated diverticulitis. Complications included the presence of abscess, microperforation, or frank perforation. A single PCT level was measured on initial patient presentation to the emergency department. The mean PCT value and standard deviation of each group was then calculated. Results: A total of 8 patients with acute diverticulitis had PCT levels measured on initial presentation. In patients with uncomplicated diverticulitis (n=5), mean PCT level was .058 ng/ml SD of ± 0.02. Three patients had evidence of a complication on CT scan including abscess (n=2), and microperforation (n=1). For complicated diverticulitis, the mean PCT level in patients with an abscess was 0.13 ng/ml SD of ± 0.03. In the presence of microperforation, PCT level was 0.32 ng/ml. In addition, one patient within the uncomplicated diverticulitis group (PCT level of 0.05 ng/ml) developed frank perforation with sepsis and repeat PCT level was 4.57 ng/ml. Statistical analysis could not be applied due to sample size. Conclusion: Procalcitonin levels in the setting of acute uncomplicated diverticulitis remain within physiologic range. Those with complicated diverticulitis did have levels >0.1 ng/ml.

Aims Acute diverticulitis (AD) is one of the major acute surgical conditions which need either hospital admission or a dedicated ambulatory care services in order to provide conventional antibiotics therapy. Regular use of antibiotics for all cases of acute diverticulitis has recently been challenged. The aim is to evaluate the necessity of antibiotics in patients presenting with CT proven uncomplicated AD. Method A systematic search was undertaken and relevant published randomized controlled trials (RCT) were shortlisted according to the inclusion criteria. Summated outcomes, including failure to response to intervention, recurrence rates and surgery during the acute admission, were analyzed using the principles of meta-analysis on RevMan 5 statistical software. Result Four RCTs on 1756 patients who presented with CT-proven uncomplicated diverticulitis were included in this review. There were 879 patients in the antibiotics group (AG) and 877 patients in the no-antibiotics group (NAG). The failure to response to intervention (use of intravenous antibiotics) was not statistically significant between the two groups, however slight statistical favour was observed in AG [OR 0.49, 95% CI (0.22–1.06), z=1.81, p=0.07]. There was no statistical difference related to recurrence rates of acute diverticulitis between the two groups. Finally, the need of surgical intervention following both interventions was also statistically similar [OR 0.63, 95% CI (0.29–1.36), z=1.18, p=0.24]. Conclusion The use of antibiotics in patients with CT proven uncomplicated AD does not seem to improve the short-term outcomes; therefore it can be carefully omitted in selected patients. More RCTs of robust quality are required to validate these findings.

Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis. To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis. MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020. Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes. 6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies. Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies). The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect. Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions. Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Commentary on: Chabok A, Påhlman L, Hjern F, et al., AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012;99:532–9.[OpenUrl][1][CrossRef][2][PubMed][3] Diverticular disease affects one...

Current guidelines recommend routine follow-up colonoscopy after acute diverticulitis to confirm the diagnosis and exclude malignancy. Its value, however, has recently been questioned because of contradictory study results. Our objective was to compare the colonoscopic detection rate of advanced colonic neoplasia (ACN), comprising colorectal cancer (CRC) and advanced adenoma (AA), in patients after a CT-proven primary episode of uncomplicated acute diverticulitis with average risk participants in a primary colonoscopy CRC screening program. A retrospective comparison was performed of prospectively collected data from cohorts derived from two multicenter randomized clinical trials executed in the Netherlands between 2009 and 2013. 401 uncomplicated diverticulitis patients and 1,426 CRC screening participants underwent colonic evaluation by colonoscopy. Main outcome was the diagnostic yield for ACN, calculated as number of diverticulitis patients and screening participants with ACN relative to their totals, with differences expressed as odds ratios (OR). The histopathology outcome of removed lesions during colonoscopy was used as definitive diagnosis. AA detection was similar [5.5 vs. 8.7%; OR 0.62 (95% CI 0.38-1.01); P = 0.053]. CRC was detected in 1.2% (5/401) of diverticulitis patients versus 0.6% (9/1,426) of screening participants [OR 1.30 (95% CI 0.39-4.36); P = 0.673]. ACN was diagnosed in 6.7% (27/401) of diverticulitis patients versus 9.1% (130/1,426) of screening participants [OR 0.71 (95% CI 0.45-1.11); P = 0.134]. ORs were adjusted for age, family history of CRC, smoking, BMI, and cecal intubation rate. ACN detection does not differ significantly between patients with recent uncomplicated diverticulitis and average risk screening participants. Routine follow-up colonoscopy after primary CT-proven uncomplicated left-sided acute diverticulitis can be omitted; these patients can participate in CRC screening programs. Follow-up colonoscopy may be beneficial when targeted at high-risk patients, but such an approach first needs prospective evaluation.

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. 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. 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. 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.

IntroductionRecently, antibiotics use in uncomplicated acute diverticulitis (AD) has been controversial in Europe. The American Gastroenterological Association (AGA) in their 2015 guidelines recommend their selective use. Our study highlights their role in outpatient management.MethodsWe queried the Diamond Network through TriNetX‐Research Network including 92 healthcare organizations. We included large intestine diverticulitis without perforation, abscess or bleeding. Exclusion criteria included any of sepsis criteria, CRP > 15 mg/L, immunodeficiency or HIV, coronary artery disease, chronic kidney disease, history of Crohn's disease or ulcerative colitis, heart failure, hypertension, diabetes or any of the following in the 3 months before study date; clostridium difficile (C. diff) infection, diverticulitis or antibiotics. Patients with AD were divided into two cohorts; patients on antibiotics, and patients not on antibiotics. Cohorts were compared after propensity‐score matching (PSM).Results214,277 patients met inclusion criteria. 58.9% received antibiotics, and 41% did not. After PSM, both cohorts had 84,320. Rate of hospital admission was lower in the antibiotic group (3.3% vs 4.2%, p < .001). There was a statistical difference between ICU admission (0.1% vs 0.15%, p < .01) and the rate of bowel perforation, peritonitis, abscess formation or bleeding (1.3% vs 1.4%, p = .044). There was no difference in mortality (0.1% vs 0.1%, p = .11), C. diff (0.1% vs 0.1%, p = .9), colectomies (0.2% vs 0.2%, p = .33), or Acute Kidney Injury (AKI) (0.1% vs 0.1%, p = .28).ConclusionOutpatient use of antibiotics in patients with uncomplicated AD is associated with lower rates of hospital admissions and complications without changing mortality rate or surgical intervention.

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. The purpose of this study was to compare the safety, effectiveness, and outcomes in treating uncomplicated acute diverticulitis without antibiotics with treatment with antibiotics. PubMed, Embase, Clinicaltrials.gov, and the Cochrane Library were searched with the key words antibiotics and diverticulitis. All studies published in English on treating uncomplicated acute diverticulitis without antibiotics and containing >20 individuals were included. Treatment without antibiotics versus treatment with antibiotics were compared. 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. 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). Only a limited number of studies were available, and they were of variable qualities. 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.