Antibiotics May Not Improve Outcomes in Uncomplicated Left-Sided Diverticulitis

EBM Focus - Volume 8, Issue 9

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Reference: Cochrane Database Syst Rev 2012 Nov 14;(11):CD009092 (level 2 [mid-level] evidence

Practice parameters from the American Society of Colon and Rectal Surgeons (ASCRS) recommend oral or IV broad-spectrum antibiotics for nonoperative management of acute left-sided diverticulitis (Dis Colon Rectum. 2006 Jul;49(7):939-44), and antibiotic treatment has become the standard of care for uncomplicated disease. However, little research has been performed to assess the efficacy of this approach. A recent Cochrane review identified only 1 unblinded trial that compared antibiotics to no antibiotics in patients with uncomplicated left-sided diverticulitis.

In this trial, 623 patients (mean age 57 years) with acute uncomplicated left-sided diverticulitis verified by computed tomography were randomized to broad-spectrum antibiotics for ≥ 7 days vs. no antibiotics and followed for 1 year (Br J Surg 2012 Apr;99(4):532). Initial IV treatment was a combination of a second- or third-generation cephalosporin and metronidazole, or carbapenem antibiotics, or piperacillin-tazobactam. IV treatment was followed by oral antibiotics (ciprofloxacin or cefadroxil with metronidazole). All patients received IV fluids.

There were no significant differences between the groups in any clinical outcomes. Recurrent diverticulitis with hospital readmission occurred in 15.8% with antibiotics vs. 16.2% without antibiotics. Complications (including sigmoid perforations or abscesses) occurred in 1% with antibiotics vs. 1.9% without, and sigmoid resections were performed in 1.6% vs. 2.3%. The median hospital stay was 3 days in each group.

The 2 other trials included in the Cochrane review addressed the comparative efficacy of different antibiotic regimens, and found no significant differences in outcomes comparing short duration of IV treatment vs. > 7 days of IV treatment (1 trial with 44 patients) or comparing cefoxitin vs. gentamicin plus clindamycin (1 trial with 51 patients).

For more information, see the Diverticulitis topic in DynaMed.