Dichman ML, Rosenstock SJ, Shabanzadeh DM Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2022 Jun 22;6:CD009092. doi: 10.1002/14651858.CD009092.pub3. (Systematic review)

BACKGROUND: Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis has been regarded as an infectious disease. Risk factors for diverticulitis, however, may suggest that the condition is inflammatory rather than infectious which makes the use of antibiotics questionable.

OBJECTIVES: The objectives of this systematic review were to determine if antibiotic treatment of uncomplicated acute diverticulitis affects the risk of complications (immediate or late) or the need for emergency surgery.

SEARCH METHODS: For this update, a comprehensive systematic literature search was conducted in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform on February 2021.

SELECTION CRITERIA: Randomised controlled trials (RCTs), including all types of patients with a radiologically confirmed diagnosis of left-sided uncomplicated acute diverticulitis. Comparator and interventions included antibiotics compared to no antibiotics, placebo, or to any other antibiotic treatment (different regimens, routes of administration, dosage or duration of treatment). Primary outcome measures were complications and emergency surgery. Secondary outcomes were recurrence, late complications, elective colonic resections, length of hospital stay, length to recovery of symptoms, adverse events and mortality.

DATA COLLECTION AND ANALYSIS: Two authors performed the searches, identification and assessment of RCTs and data extraction. Disagreements were resolved by discussion or involvement of the third author. Authors of trials were contacted to obtain additional data if needed or for preliminary results of ongoing trials. The Cochrane Collaboration's tool for assessing risk of bias was used to assess the methodological quality of the identified trials. The overall quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effect estimates were extracted as risk ratios (RRs) with 95% confidence intervals. Random-effects meta-analyses were performed with the Mantel-Haenzel method.

MAIN RESULTS: The authors included five studies. Three studies compared no antibiotics to antibiotics; all three were original RCTs of which two also published long-term follow-up information.  For the outcome of short-term complications there may be little or no difference between antibiotics and no antibiotics (RR 0.89; 95% CI 0.30 to 2.62; 3 studies, 1329 participants; low-certainty evidence). The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics (RR 0.47; 95% CI 0.13, 1.71; 1329 participants; 3 studies; low-certainty evidence). However, there is considerable imprecision due to wide confidence intervals for this effect estimate causing uncertainty which means that there may also be a benefit with antibiotics. One of the two remaining trials compared single to double compound antibiotic therapy and, due to wide confidence intervals, the estimate was imprecise and indicated an uncertain clinical effect between these two antibiotic regimens (RR 0.70; 95% CI 0.11 to 4.58; 51 participants; 1 study; low-certainty evidence). The last trial compared short to long intravenous administration of antibiotics and did not report any events for our primary outcomes. Both trials included few participants and one had overall high risk of bias. Since the first publication of this systematic review, an increasing amount of evidence supporting the treatment of uncomplicated acute diverticulitis without antibiotics has been published, but the total body of evidence is still limited.

AUTHORS' CONCLUSIONS: The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications. The quality of the evidence is low. Only three RCTs on the need for antibiotics are currently available. More trials are needed to obtain more precise effect estimates.

Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Internal Medicine 6 / 7
Gastroenterology 6 / 7
Surgery - General 6 / 7
Surgery - Gastrointestinal 5 / 7
Comments from MORE raters

Gastroenterology rater

Interesting challenge to prevalent practice. Likely of even greater relevance to general surgery than to gastroenterology.

General Internal Medicine-Primary Care(US) rater

As an internist, this is a common call from patients with this disorder. They all believe they need antibiotics. I look forward to more studies as antibiotic overuse is a huge problem. The treatment duration also needs to be sorted out when antibiotics are used.

Internal Medicine rater

As a hospitalist, this topic is often unclear with providers resorting to varying practices based on a clinical picture. This review does not help to establish any particular direction for this question and needs additional evidence.

Internal Medicine rater

Looking it over, I'm surprised by the very wide confidence intervals that include both potential major benefit and potential major harm. Sounds like we need a much larger trial.

Surgery - Gastrointestinal rater

Unfortunately, this systematic review is not helpful in clinical decision-making partly due to the difficulty with defining uncomplicated diverticulitis. Most patients with non-specific left-lower abdominal tenderness without CT imaging may improve with or without antibiotics. Unfortunately, the group that are seen in the emergency and are admitted into hospital frequently have a severe inflammatory process and fluid complications. In this group, aggressive non-operative management may reduce the need for urgent invasive procedures.

Surgery - General rater

The 2 questions that need to be explored in this setting are the need (or not) for antibiotics and the type of antibiotic. In the review, only 3 studies explored the former question. Although these were RCTs with 2 including long-term follow-up, the treatment effects were imprecise. Having noted that, the authors did not find that antibiotic use leads to improved outcomes with regard to short-terms aspects - complications, emergency surgery, recurrence, elective colonic resections, or long-term complications. The quality of evidence is mostly low and moderate at best. These problems persisted with regard to the selection of antibiotics, mono versus dual therapy, and short- versus long-term therapy. More studies are clearly needed to assess the utility or not of antibiotics for diverticulitis.
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