Antibiotic treatment for uncomplicated and mild complicated diverticulitis: outpatient treatment for everyone

Joliat, Gaëtan‐Romain; Emery, Jonathan D.; Demartines, Nicolas; Yersin, Bertrand; Hahnloser, Dieter

doi:10.1007/s00384-017-2847-z

Cited by 22 publications

(18 citation statements)

References 25 publications

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“…This paper defines ambulatory care as an in-patient hospital stay up to 24 h only, with discharge to continue treatment at home in an out-patient setting either on oral antibiotics or with an outpatient IV service. This is confirmed by a recent paper by Joliat et al [30] who employed a similar outpatient treatment strategy. These authors found that factors including increasing time to admission CT, Ambrosetti score of 4 and free air around the colon were predictive of treatment failure [30].…”

Section: Inpatient Verses Outpatientsupporting

confidence: 78%

“…This is confirmed by a recent paper by Joliat et al [30] who employed a similar outpatient treatment strategy. These authors found that factors including increasing time to admission CT, Ambrosetti score of 4 and free air around the colon were predictive of treatment failure [30]. Assuming equivalent patient outcomes, it follows that outpatient treatment can lead to significant savings on health care costs: An Italian group quantified the economic burden of diverticulitis as EUR 3,826 per patient per year, of which, EUR 3,653 for hospital fees, might be avoided.…”

Section: Inpatient Verses Outpatientsupporting

confidence: 78%

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Current Controversies in the Management of Diverticulitis: A Review

Nally

Kavanagh

2018

Dig Surg

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Background: Symptomatic diverticular disease is challenging for patients, clinicians and health services. The prevalence increases with age and BMI and as such, the burden of this disease is set to increase with higher rates of acute presentations already documented. The natural history of recurrent episodes, complications and symptom progression is not fully understood. Furthermore, medical and surgical management strategies are under constant appraisal, debate and evolution. Methods: A review of the contemporary literature was performed to examine the emerging trend towards conservative treatment. Results: Routine use of in-patient, intravenous antibiotics may not be required and outpatient management is possible for certain patients. Universal colonoscopy examination after uncomplicated acute diverticulitis is controversial but is mandatory after complicated episodes. Recent, high-profile, clinical trials suggest that less aggressive surgical management of both acute and chronic presentations may be feasible in some cases. Conclusions: Diverticulitis is a common yet challenging topic that demands clinicians to provide an individualised yet evidence-based approach.

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Section: Inpatient Verses Outpatientsupporting

confidence: 78%

Section: Inpatient Verses Outpatientsupporting

confidence: 78%

Current Controversies in the Management of Diverticulitis: A Review

Nally

Kavanagh

2018

Dig Surg

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“…Most studies selected patients as outpatient treatment candidates based on patient characteristics (such as absence of comorbidities or immunosuppressed state), clinical condition (such as having uncomplicated diverticulitis and ability to tolerate oral intake) and patients’ social environment (adequate family and social network). Importantly, seven studies [ 22 , 28 , 29 , 31 , 33 – 35 ] also included patients with diverticular abscesses as candidates for outpatient treatment. Although most studies used outpatient treatment protocols that could be used in almost all hospitals (ambulatory treatment at home with an outpatient clinic visit after 4 to 7 days), 3 studies treated their patients in a ‘hospital at home unit’ or ‘home care unit’ [ 26 , 27 , 33 ].…”

Section: Resultsmentioning

confidence: 99%

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis

Dijk

Bos

Boer

et al. 2018

Int J Colorectal Dis

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BackgroundThe 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.PurposeAssessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.MethodsPubMed 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.ResultsA 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%, I2 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%.ConclusionOutpatient 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.Electronic supplementary materialThe online version of this article (10.1007/s00384-018-3015-9) contains supplementary material, which is available to authorized users.

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“…Treatment failure rates of 3–24% are reported, depending on the definition of treatment failure [7–12]. Reported risk factors for treatment failure are female gender, free fluid or free air around the colon on CT scan, comorbidity (Ambrosetti score > 3), and an ER admission time between midnight and 6 AM [8, 9]. These studies are however hampered by the fact that all patients received antibiotics, which is now considered a redundant treatment strategy.…”

Section: Discussionmentioning

confidence: 99%

“…Few studies have investigated clinical risk factors for treatment failure in patients with UD. In the few studies that are available, all patients received antibiotics [8, 9]. The aim of the current study is to assess the clinical course of UD patients who were initially treated without antibiotics and to identify risk factors for treatment failure in this patient group.…”

Section: Introductionmentioning

confidence: 99%

Treatment of acute uncomplicated diverticulitis without antibiotics: risk factors for treatment failure

Bolkenstein

Draaisma

Wall

et al. 2018

Int J Colorectal Dis

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PurposeConservative treatment strategy without antibiotics in patients with uncomplicated diverticulitis (UD) has proven to be safe. The aim of the current study is to assess the clinical course of UD patients who were initially treated without antibiotics and to identify risk factors for treatment failure.MethodsA retrospective cohort study was performed including all patients with a CT-proven episode of UD (defined as modified Hinchey 1A). Only non-immunocompromised patients who presented without signs of sepsis were included. Patients that received antibiotics within 24 h after or 2 weeks prior to presentation were excluded from analysis. Patient characteristics, clinical signs, and laboratory parameters were collected. Treatment failure was defined as (re)admittance, mortality, complications (perforation, abscess, colonic obstruction, urinary tract infection, pneumonia) or need for antibiotics, operative intervention, or percutaneous abscess drainage within 30 days after initial presentation. Multivariable logistic regression analyses were used to quantify which variables are independently related to treatment failure.ResultsBetween January 2005 and January 2017, 751 patients presented at the emergency department with a CT-proven UD. Of these, 186 (25%) patients were excluded from analysis because of antibiotic treatment. A total of 565 patients with UD were included. Forty-six (8%) patients experienced treatment failure. In the multivariable analysis, a high CRP level (> 170 mg/L) was a significant predictive factor for treatment failure.ConclusionUD patients with a CRP level > 170 mg/L are at higher risk for non-antibiotic treatment failure. Clinical physicians should take this finding in consideration when selecting patients for non-antibiotic treatment.

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Antibiotic treatment for uncomplicated and mild complicated diverticulitis: outpatient treatment for everyone

Abstract: 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.

Cited by 22 publications

References 25 publications

Current Controversies in the Management of Diverticulitis: A Review

Current Controversies in the Management of Diverticulitis: A Review

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis

Treatment of acute uncomplicated diverticulitis without antibiotics: risk factors for treatment failure

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