Acute uncomplicated diverticulitis managed without antibiotics – difficult to introduce a new treatment protocol but few complications

Abstract

Objective: Routine antibiotic treatment of acute uncomplicated diverticulitis (AUD) has been shown ineffective. In this study, the adherence to a new treatment protocol for uncomplicated diverticulitis was evaluated and the incidence of complications in patients treated with and without antibiotics was investigated. Materials and methods: A retrospective study of in-patients diagnosed with AUD at Helsingborg Hospital, Sweden between 01 January 2013 and 06 January 2015 was performed. Antibiotics were routinely administrated until 01 May 2014. Thereafter, a new antibiotic-free treatment protocol for uncomplicated diverticulitis was introduced. All the patients were followed regarding complications for minimum one year. Results: A total of 50 patients were studied after the new protocol implementation and, 60% (n ¼ 31) of the patients were treated without antibiotics. Specialists initiated antibiotic therapy significantly more often than registrars (p¼.03). More patients in the antibiotic group had comorbidities (p¼.03), apart from that, no significant differences in baseline characteristics were noted between treatment groups. Patients treated with antibiotics after introduction of the new protocol had significantly higher C-reactive protein than patients managed without antibiotics (median 117 mg/L vs. 70, p¼.005). The hospital stay was shorter in the non-antibiotic group (three days vs. two days; p¼.008). No significant differences in complications were observed. Conclusions: Protocol compliance was lower than expected, indicating that implementation of new treatment regimens is challenging. This study confirms that complications are rare in AUD treated without antibiotics. However, the selection of the sickest patients to the treatment with antibiotics limits the interpretation of the results.

International Consensus on Diverticulosis and Diverticular Disease. Statements from the 3rd International Symposium on Diverticular Disease

“…The first claims that the management of acute diverticulitis without antibiotics does not increase these worse outcomes [63][64][65][66][67][68]. Therefore, the second statement confirms that antibiotics have to be used by a "case-by-case" basis [5,66], and that some parameters (namely levels of PCR and CT findings at entry) may be predictive on the need to use antibiotics in this population (48,66). The last three statement confirms that the open or the laparoscopic approach to AD, as well as an elective resection after multiple episode of AD have to follow a "caseby-case" basis [69,73].…”

Management of acute uncomplicated diverticulitis without antibiotics: compliance and outcomes -a retrospective cohort study

“…To the best of our knowledge, the present study is unique in evaluating clinicians’ compliance to a new protocol of AUD management over time and comparing results to another hospital without a protocol. Unexpectedly physicians’ compliance at the reference hospital (HH) had declined compared to just after introduction of the protocol (60% vs 48% managed without antibiotics) [ 16 ]. However, at the hospital without a standard treatment protocol (SUS), only 11% of AUD patients were managed without antibiotics.…”

“…In 2014, a new treatment protocol (omitting antibiotics) was introduced at Helsingborg Hospital (HH) Sweden [ 16 ], where the exclusion criteria were similar to those in the AVOD-study (Antibiotika Vid Okomplicerad Divertikulit) [ 6 ]. Complications were rare, and compliance to the protocol was 60%.…”

Tratamiento ambulatorio de la diverticulitis aguda no complicada

“…También existen experiencias negativas respecto al manejo sin antibioterapia no referidas a la eficacia, ni eficiencia del mismo, sino a la adherencia de los pacientes. Azhar et al 20 han publicado recientemente sus dificultades para introducir un nuevo protocolo de tratamiento en sus prácticas clínicas, con una aceptación por parte de los pacientes más baja de la esperada. Insisten en que es preciso una buena selección de los pacientes de cara a instaurar estos protocolos de tratamiento, términos en los que estamos de acuerdo.…”