Need for Antibiotics in Cases of Acute Uncomplicated Diverticulitis: A Meta-Analysis of Conservative Versus Antibiotic Treatment Approaches

TL;DR

This study finds that antibiotics may not be necessary for some patients with mild diverticulitis, as non-antibiotic treatment leads to similar outcomes.

Contribution

The study provides a meta-analysis comparing antibiotic and conservative treatment for acute uncomplicated diverticulitis, supporting selective antibiotic use.

Findings

No significant differences in mortality, complications, or surgery rates between antibiotic and conservative treatment.

Length of hospital stay was marginally shorter with conservative treatment.

Findings support selective antibiotic use in clinically stable patients with acute uncomplicated diverticulitis.

Abstract

Acute uncomplicated diverticulitis (AUD) is often treated with antibiotics, though recent evidence questions their necessity in clinically stable patients. Concerns over antibiotic resistance have prompted consideration of conservative, non-antibiotic management, but clinical equivalence remains debated. This study aimed to compare antibiotic versus non-antibiotic management for CT (computed tomography)-confirmed AUD in adults, focusing on outcomes like mortality, complications, recurrence, surgery, and length of hospital stay (LOS). A systematic search (2016-2025) was carried out across five databases, identifying randomized controlled trials (RCTs) comparing antibiotic to conservative treatment in patients with Hinchey 1a/1b or Modified Neff grade 0 diverticulitis. Two reviewers independently extracted data and assessed bias using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcomes were analyzed using a DerSimonian-Laird random-effects model. Seven RCTs (n = 8,035) met inclusion criteria. No significant differences were found in mortality (odds ratio (OR) 1.06; 95% CI: 0.71-1.58), complications (OR 0.67; 95% CI: 0.27-1.67), emergency surgery (OR 0.60; 95% CI: 0.23-1.54), or recurrence (OR 0.96; 95% CI: 0.65-1.44). LOS was marginally shorter in the conservative group. Heterogeneity for mortality and LOS was moderate (I² = 43.2%). Most studies defined clinical stability based on the absence of systemic signs and CT-confirmed localized inflammation; some variations in diagnostic criteria were noted. Conservative treatment without antibiotics in select AUD patients yields comparable outcomes to antibiotic use. These findings support guideline recommendations favoring selective antibiotic use, though heterogeneity in population definitions and short follow-up in some studies should be noted.

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