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Antibiotic treatment is regarded as standard care in managing patients with uncomplicated acute diverticulitis. Recently, however, the first randomized double-blind trial in such patients reported that withholding antibiotics did not prolong length of hospital stay or increase adverse events. These findings have implications for hospital resources, patient care, and antibiotic stewardship.

In , Ian Bissett, MD, of the University of Auckland, and colleagues recruited 180 patients in their late 50s who were hospitalized in New Zealand and Australia for uncomplicated acute diverticulitis; 85 patients were randomized to antibiotics and 95 to placebo for 7 days.

Bissett and team found no significant difference in median time of hospital stay between the antibiotic group (40 hours, 95% CI 24.4-57.6 hours) and the placebo group (45.8 hours, 95% CI 26.5-60.2 hours, P=0.2). Nor were there notable inter-arm differences in adverse events (12% for both, P=1.0), or in readmission to hospital within 1 week (6% for the placebo group vs 1% for the antibiotic group, P=0.1) and readmission within 30 days (6% for the placebo group vs 11% for the antibiotic group, P=0.3).

These results provide strong evidence for omitting antibiotics in selected patients with uncomplicated acute diverticulitis.

What was the initial impetus for undertaking this trial?

Bissett: This trial was initiated in response to two open-label unblinded randomized controlled trials, the by Daniels and colleagues in 2016, which demonstrated no advantage in the antibiotics group versus placebo. But a study that was truly blinded was needed to convince us all that this approach is safe.

Did it arise at all from observational outcomes at your center?

Bissett: No, our center was routinely giving antibiotics to all patients with acute diverticulitis. But we thought the evidence for omitting antibiotics was quite strong, so our hypothesis was that antibiotics were not required unless there was evidence of perforation.

Why was duration of hospitalization the primary endpoint?

Bissett: Length of hospital stay is an outcome of interest to patients, clinicians, and healthcare systems. For patients with uncomplicated acute diverticulitis, more severe outcomes such as the need for procedural management or death are rare, while extended length of hospital admission represents a more immediate concern.

Did any aspect of the study surprise you?

Bissett: I was surprised that patients were so willing to participate in the study. There is a real sense that patients don't want to take antibiotics if they're not needed.

Will the results have an immediate pragmatic impact on managing diverticulitis patients at your facility?

Bissett: We would now like to investigate patients who present at the hospital with an early computed tomography scan and identify for treatment those who have complications evident on the CT or who have evidence of sepsis; for example, those exhibiting systemic inflammatory response syndrome.

Who will still need antibiotics?

Bissett: Patients with complicated diverticulitis, including those with an abscess, free perforation, and peritonitis, as well as patients with evidence of systemic sepsis, and those who are immunocompromised.

Are you planning any further research in this area?

Bissett: We would like to consider discharging uncomplicated diverticulitis patients immediately, offering pain relief and outpatient management for those who meet the criteria we used for entry into this study. This would save 4 days in hospital on average, but would require a fast track to CT scan for patients who present at the hospital.

What is the broad significance of your findings?

Bissett: This study probably has an even more important implication for those managing patients with acute diverticulitis in the community. Repeated courses of antibiotics may not be in the patients' best interest.

You can read the abstract of the study here and read about the clinical implications of the study here.