Which Patients are Eligible for Initial Treatment without Antibiotics?

The list of those who should receive antibiotics is intuitive—patients with high-risk comorbidities or those patients with severe diverticular disease. In the randomized trials supporting the guideline recommendations, patients could have clinical signs of inflammation (fever, leukocytosis, tachycardia); however, patients could not have signs of sepsis or more than one of these features. Perhaps surprisingly, elderly patients do not automatically fall into a high-risk category. The DIABOLO trial did not have an upper age limit for exclusion and the DINAMO study randomized patients up to age 80. Further, updated guidelines from the World Society of Emergency Surgery recommend that antibiotics be avoided in elderly immunocompetent patients with acute, uncomplicated diverticulitis.¹¹

In medicine, particularly in the United States, we have a preference for aggressive, interventional treatment—more is often conflated with better. As a result, the de-implementation of low-value treatments is particularly difficult for clinicians. There are several potential avenues that may ease the change brought by these guidelines and help clinicians provide high-quality care to patients.

• Share the plethora of national professional society guidelines with your group to help establish local practice patterns.
• Develop a quick script for patients who meet the criteria for non-antibiotic treatment that pre-empts expectations for antibiotics and establishes confidence in non-antibiotic treatment (e.g., recommended by specialists who focus on diverticular disease).
• Provide symptomatic treatment with analgesia.
• Consider a “wait and see” prescription and guidance for select patients.

Follow the QR code for more:

Dr. Westafer (@Lwestafer) is an attending physician and research fellow at Baystate Medical Center, clinical instructor at the University of Massachusetts Medical School in Worcester, and co-host of FOAMcast.

References

1. Radecki RP, MS. Antibiotics, hospital admission may not help uncomplicated diverticulitis. ACEP Now. Published February 12, 2016. Accessed February 3, 2023. https://www.acepnow.com/article/antibiotics-hospital-admission-may-not-help-uncomplicateddiverticulitis/.
2. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015;149(7):1944-1949.
3. Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K, AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99(4):532-539.
4. Daniels L, Ünlü Ç, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104(1):52-61.
5. Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, et al. Diagnosis and management of acute left-sided colonic diverticulitis: a clinical guideline from the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.
6. Hall J, Hardiman K, Lee S, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020;63(6):728-747.
7. Azhar N, Aref H, Brorsson A, et al. Management of acute uncomplicated diverticulitis without antibiotics: compliance and outcomes -a retrospective cohort study. BMC Emerg Med. 2022;22(1):28.
8. Mora-López L, Ruiz-Edo N, Estrada-Ferrer O, et al. Efficacy and safety of nonantibiotic outpatient treatment in mild acute diverticulitis (DINAMO-study): a multicentre, randomised, open-label, noninferiority trial. Ann Surg. 2021;274(5):e435-e442.
9. van Dijk ST, Daniels L, Ünlü Ç, et al. Long-Term effects of omitting antibiotics in uncomplicated acute diverticulitis. Am J Gastroenterol. 2018;113(7):1045-1052.
10. Jaung R, Nisbet S, Gosselink MP, et al. Antibiotics do not reduce length of hospital stay for uncomplicated diverticulitis in a pragmatic double-blind randomized trial. Clin Gastroenterol Hepatol. 2021;19(3):503-510.e1.
11. Fugazzola P, Ceresoli M, Coccolini F, et al. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg. 2022;17(1):5.