Sunday, 16 October 2016

No antibiotics for outpatient management of uncomplicated diverticulitis?

Crazy?

A long standing dictum in medicine is the mandatory treatment of acute diverticulitis with antibiotics. However there are now a couple of clinical trials proving that many cases of uncomplicated disease will recover with supportive care alone.

But before we alter our practice, it would be nice to see several studies of high quality evidence providing us a foundation for change. This paper certainly is not high quality evidence but it does add to the body of literature building out of Europe.

This was a descriptive study conducted in two Swedish hospitals that followed a convenience sample of 155 patients diagnosed with CT proven uncomplicated diverticulitis. They were managed without antibiotics and followed up as outpatients.

The mean age of patients was 57 and the mean CRP was 73. The majority had their first presentation of diverticulitis.

How successful was this strategy?

97% did just fine and recovered without complications... wow.

Of course there are some problems with this study design (selection bias, no comparator group, silly power calculation, unnecessary inferential statistics, etc) but it is compelling.

Sure, the literature is starting to look more definitive on this subject, but I’m not sure I have the cojones to change my practice quite yet... call me a eunuch.

I could only imagine having one of my patients return as a failure and have a surgeon castigate (castrate?) me.  In addition, I’m not sure this is the time & place to be making a substantial impact on antibiotics stewardship. Think URTI’s, bronchitis, otitis media, chickens...

I think it’s looking like antibiotics do have some minor effect. The number needed to treat for acute uncomplicated mild disease is probably somewhere between 30 to 50. This might be enough reason to continue our current practice. But, I could be proven wrong.


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