Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial

Abstract

BACKGROUND & AIMS: Antibiotic treatment is the standard care for patients with uncomplicated acute diverticulitis. However, this practice is based on low-level evidence and has been challenged by findings from 2 randomized trials, which did not include a placebo group. We investigated the non-inferiority of placebo vs antibiotic treatment for the management of uncomplicated acute diverticulitis. METHODS: In the selective treatment with antibiotics for non-complicated diverticulitis study, 180 patients hospitalized for uncomplicated acute diverticulitis (determined by computed tomography, Hinchey 1a grade) from New Zealand and Australia were randomly assigned to groups given antibiotics (n [ 85) or placebo (n [ 95) for 7 days. We collected demographic, clinical, and laboratory data and answers to questionnaires completed every 12 hrs for the first 48 hrs and then daily until hospital discharge. The primary endpoint was length of hospital stay; secondary endpoints included occurrence of adverse events, readmission to the hospital, procedural intervention, change in serum markers of inflammation, and patient-reported pain scores at 12 and 24 hrs. RESULTS: There was no significant difference in median time of hospital stay between the antibiotic group (40.0 hrs; 95% CI, 24.4-57.6 hrs) and the placebo group (45.8 hrs; 95% CI, 26.5-60.2 hrs) (P [ .2). There were no significant differences between groups in adverse events (12% for both groups; P [ 1.0), readmission to the hospital within 1 week (1% for the placebo group vs 6% for the antibiotic group; P [ .1), and readmission to the hospital within 30 days (11% for the placebo group vs 6% for the antibiotic group; P [ .3). CONCLUSIONS: Foregoing antibiotic treatment did not prolong length of hospital admission. This result provides strong evidence for omission of antibiotics for selected patients with uncomplicated acute diverticulitis. ACTRN: 12615000249550.

Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis

“…That study showed that antibiotic treatment neither prevents complications and recurrences nor does it reduce symptoms or length of hospital stay. The findings were confirmed in two other RTCs with patient cohorts from Netherlands and New Zealand/Australia ( 33 , 34 ). In addition, several prospective cohort studies with similar findings, from different countries have been published ( Table 1 ) ( 20 , 36 , 38 , 39 ).…”

Efficacy and Safety of a Strategy for Reviewing Intravenous Antibiotics for Hospitalized Japanese Patients with Uncomplicated Diverticulitis: A Single-center Observational Study

“…Two retrospective studies with 311 and 272 patients with uncomplicated diverticulitis found that treatment without antibiotics appears to be safe (16,17). A more recent double-blind, randomized controlled trial revealed the noninferiority of placebo compared with antibiotic management for uncomplicated acute diverticulitis, which supports omitting antibiotics in some patients presenting with uncomplicated acute diverticulitis (7). In secondary-care clinical practice in Japan, most cases of diverticulitis are evaluated by CT at the first visit.…”

“…Therefore, previous Japanese studies on patients with diverticulitis showed that hospital stays were approximately 8-10 days ( 4 , 5 ). Although recent randomized controlled studies of uncomplicated diverticulitis have revealed no significant differences in outcomes with or without antibiotics ( 6 , 7 ), a rapid change to a no-antibiotic strategy is unacceptable because of the lack of evidence in Asian countries ( 3 ). In general, the duration of antibiotic treatment depends on the physician's judgment.…”

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“…Patients with uncomplicated acute diverticulitis are commonly treated with antibiotics; however, in recent RCTs, this has been omitted for acute uncomplicated diverticulitis, which is characterized by elevated body temperature, inflammatory parameters, except for sepsis, and any sign of complications, such as abscess, free air, or fistula on computed tomography. Moreover, an earlier study demonstrated that the median hospital stay duration, adverse events, and hospital readmission were not significantly different during antibiotic treatment and observation 66 . In a 1‐year follow‐up of patients with uncomplicated diverticulitis, the rates of ongoing, recurrent, and complicated diverticulitis and undergoing sigmoid resection were not significantly different during antibiotic treatment and observation 67 .…”

“…Moreover, an earlier study demonstrated that the median hospital stay duration, adverse events, and hospital readmission were not significantly different during antibiotic treatment and observation. 66 In a 1‐year follow‐up of patients with uncomplicated diverticulitis, the rates of ongoing, recurrent, and complicated diverticulitis and undergoing sigmoid resection were not significantly different during antibiotic treatment and observation. 67 These results provide evidence for the omission of antibiotics in patients with uncomplicated acute diverticulitis.…”