I’ve talked about the inflammatory vs. infectious theory for diverticulitis in a couple of my national and international presentations, and I’ve talked about the evidence supporting an observation-only strategy. Until now, that evidence was mostly a single-center randomized trial from Finland, followed by an observational report from the same.
Now, this non-treatment paradigm has migrated across the little river between Scandanavia and Europe, and has been taken up by the Dutch in this latest randomized trial. In this trial, 22 clinical sites randomized 570 patients with uncomplicated diverticulitis to either admission for antibiotic treatment, or observation and disposition per clinical stability. The antibiotic chosen was amoxicillin-clavulanic acid, with ciprofloxacin/metronidazole in the case of allergy. The primary outcome was time to recovery, with secondary outcomes relating to complications and recurrence.
Of the 570 randomized, ultimately, only 528 were analyzed. A handful were lost to follow-up, and then 35 patients withdrew from the study after allocation – 22 in the observation cohort and 13 in the antibiotics cohort. There were minor, potentially confounding differences between the two cohorts analyzed – about 8% more of the antibiotics cohort suffered from mild or severe comorbid disease.
Most patients selected for observation were admitted – with only 13% managed as outpatients. With respect to the primary outcome, there was no difference between cohorts in time to recovery. There were also few statistically significant differences in secondary outcomes, although the numbers suggest a small magnitude of harm relating to observation. Complications – ongoing diverticulitis within 6 months, need for sigmoid resection, and hospital readmission – all favored the antibiotic cohort by small, non-significant amounts. Conversely, morbidity numbers generally favored the observation cohort – relating mostly to antibiotic-related adverse effects.
Regardless, the sum of benefits and harms – in the context of the other evidence – supports antibiotic-free strategies for uncomplicated diverticulitis.
“Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis”
http://onlinelibrary.wiley.com/doi/10.1002/bjs.10309/abstract