Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study)

Abstract

Objective: Mild AD can be treated safely and effectively on an outpatient basis without antibiotics. Summary of Background Data: In recent years, it has shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective. Methods: A Prospective, multicentre, open-label, noninferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD. The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (antiinflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days. The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms. Results: Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) [mean difference 2.58%, 95% confidence interval (CI) 6.32 to -1.17], confirming noninferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18). Conclusions: Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment. Trial registration: ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75)

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“…Standard practice for treatment of diverticulitis without abscess, poor pain control or other systemic symptoms is discharge with antibiotics. In this Spanish study, Mora-López et al 1 demonstrate that discharging patients with symptomatic management (ibuprofen and paracetamol) is not inferior to symptomatic treatment plus with co-amoxiclav. Their patient group (n=480) were adults under 80 years with no significant comorbidities and CT-confirmed mild diverticulitis (defined using a previously derived and published scoring system).…”

Antibiotic Practice in Patients With Acute Abdomen Admitted to a Danish Regional Hospital: A Clinical Qualitative Assurance Study

“…In alignment with this approach, all patients with acute appendicitis in this study population were treated with antibiotics wherein cephalosporins were preferred in 75% of cases above the other available regimens. It is also recommended that patients suspected of acute complicated diverticulitis (abscess/perforation) should be treated with broad-spectrum antibiotic treatment early during clinical evaluation [ 15 ], whereas routine antibiotic therapy in patients with acute uncomplicated diverticulitis is not recommended, except for clinically complicated cases involving a weakened immune system, pregnancy, septicemia, and body temperature >38.5°C [ 16 ]. In our study population, 41% of uncomplicated diverticulitis patients had received antibiotic treatment due to the fulfillment of at least one of these criteria.…”

Diverticulitis With Microperforation

“…However, the Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO study) randomized 480 patients to either classic treatment with antibiotics, or to treatment with anti-inflammatory medication. They found outpatient supportive, symptomatic treatment of mild acute diverticulitis without antibiotics to be safe, effective, and non-inferior to current standard treatment [ 10 ]. This trial and other studies have led to the 2022 practice-changing update to not routinely prescribe antibiotics for uncomplicated mild acute diverticulitis.…”