Clinical question: Do antibiotics change clinical outcomes for patients with acute uncomplicated diverticulitis?
Bottom line: For nonseptic immunocompetent patients with acute uncomplicated diverticulitis, antibiotics do not alter early complication or recurrence rates.
Background: Diverticulitis accounts for over 300,000 hospitalizations annually in the United States and its incidence increases with age. Among older adults, diverticulitis is the fourth leading cause for emergency surgery. Older adults with multimorbidity and geriatric syndromes are often excluded from clinical studies, leaving a gap in the evidence needed to guide management. Here, we provide a clinically oriented review of the diagnosis and management of older adults with diverticulitis through the lens of age-friendly care.
Methods and results: We reviewed the literature describing the epidemiology, diagnosis, management, and prevention of diverticulitis in older adults. Due to age-related physiologic changes, the presence of geriatric syndromes, and multimorbidity, older adults with diverticulitis often present with atypical symptoms, variable laboratory findings, and are at higher risk for complications than younger patients. Guidelines support a more aggressive approach to diagnosis in this population, with lower threshold for obtaining diagnostic imaging. Antibiotics remain a mainstay of treatment for uncomplicated disease, and surgical management should be focused on severity of disease and the balance between the likelihood of improving quality of life and risks and burden of treatment.
Conclusions: Diverticulitis is a common disease that has a unique presentation among older individuals with limited evidence to guide management. Diagnosis and treatment should focus on what matters most to the patient, providing the most meaningful outcome possible within the context of multimorbidity, patient goals, symptom burden, and anticipated treatment outcomes.
1 Emergency department visits and hospital admissions for acute
diverticulitis have increased
Emergency department visits for acute diverticulitis increased by 26.8% to
113.9 visits per 100 000 from 2006 to 2013 in the United States.1
Hospital admissions for diverticulitis increased 7.5% annually from 190 per 100 000 in 2008 to
310 per 100 000 in 2015 in Europe; the increase occurred predominantly among
patients aged younger than 60 years.2 Insufficient consumption of dietary fibre
is associated with this rise.
2 Symptoms of diverticulitis may be driven by inflammation rather
than infection
Contemporary evidence shows that use of antibiotics in uncomplicated cases of
diverticulitis neither accelerates recovery nor improves outcomes.2
A recent
study has suggested that chronic inflammation secondary to environmental risk
factors and alterations of the gut microbiome are now favoured causes over
microperforation or bacterial translocation.3
3 Most patients with uncomplicated diverticulitis can be treated as
outpatients with nonopiate analgesia rather than antibiotics
Cross-sectional imaging that shows inflamed colonic diverticula without perforation or abscess defines uncomplicated diverticulitis. Two randomized controlled trials that compared antibiotic and nonantibiotic treatment reported
no difference in recovery time, treatment duration or rate of recurrence.4,5
Updated guidelines recommend reserving antibiotics for patients taking
immunosuppressive medications and those with sepsis.1,2 Treating symptoms
with nonopiate analgesics avoids worsening bowel function and contributing
to opiate dependence.
4 Evidence of complicated diverticulitis should prompt emergent
surgical assessment and antibiotic treatment
Complicated diverticulitis, defined as radiologic evidence of perforation or intraabdominal abscess, has a 30-day mortality rate of 8.7%.2
Antibiotic therapy is indicated, and many patients require admission to hospital.1
Percutaneous drainage
of large abscesses (> 3 cm) or emergency surgery may be required.2
5 Colonoscopy and elective colon resection are not routinely required
after resolution of uncomplicated diverticulitis
Only 8.7% of patients with uncomplicated diverticulitis will present to hospital
with a second episode.1
Elective surgery should be determined by frequency
and severity of symptoms, rather than prevention of future complications.2
Risk of malignant disease after uncomplicated left-sided diverticulitis is similar to that of the general population (1%), and standard colon cancer screening guidelines should be followed.1
Complicated diverticulitis warrants an
interval colonoscopy, typically 6 weeks after resolution.1
Not available
