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Treatment of Acute Uncomplicated Colonic Diverticulitis
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Upper Abdominal Surgery.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to evaluate the clinical management of AUD with regard to the no-antibiotic policy and its long-term effect, treatment on an outpatient basis and the potential health-care cost savings

Study I:  a retrospective study at Västmanlands Hospital that evaluated and confirmed the adherence to the no-antibiotic policy in patients with AUD and its safety regarding complications and recurrences. A total of 246 patients with acute diverticulitis were identified, of which 195 had computed tomography (CT) confirmed AUD. In total, 91.3% of these patients did not receive any antibiotics and only two developed complications.

Study II: a retrospective study with the aim to conduct a long-term follow-up of all Swedish patients who participated in the AVOD trial in terms of recurrences, complications, surgery and quality of life. The medical records of 96% of the patients were reviewed with a mean follow up of 11 years. Quality of life questionnaires were sent out to all patients. There were no differences regarding the rates of recurrence, complications or surgery for diverticulitis. There were no differences in the quality of life between groups according to the EQ-5D questionnaire.

Study III: a prospective study where 155 patients with CT-verified AUD as were treated as outpatients without antibiotics. On day 3, patients reported an average pain score of 1.8 of 10 on the VAS scale and only 30% of patients were using analgesia. Four patients returned to hospital because of treatment failure.

Study IV: a retrospective cohort study at Västmanland’s Hospital evaluated the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics. Medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics were reviewed. Overall 494 episodes of AUD were identified: 254 in 2011 and 240 in 2014. Three patients developed complications in 2011 and four in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 61% in 2014. The hospital admissions, total length of stay of and total health-care costs were almost halved.

In conclusion, these studies confirm the low complication and recurrence rates of AUD and strengthens findings that antibiotics have no benefit in the treatment of this disease. The no-antibiotic policy had no impact on short- or long-term outcomes regarding the rates of recurrence, complications, surgery or quality of life. Outpatient management was found to be feasible and safe, and significantly reduced admissions, which led to large health-care cost savings.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. , p. 48
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1522
Keywords [en]
Colonic diverticulitis, antibiotics, health-care cost, follow-up
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-369128ISBN: 978-91-513-0530-1 (print)OAI: oai:DiVA.org:uu-369128DiVA, id: diva2:1269594
Public defence
2019-02-08, Vårdskolans Aula, Västmanlands Hospital, entrance 21, Västerås, 09:00 (English)
Opponent
Supervisors
Available from: 2019-01-18 Created: 2018-12-10 Last updated: 2019-02-18
List of papers
1. No antibiotics in acute uncomplicated diverticulitis: does it work?
Open this publication in new window or tab >>No antibiotics in acute uncomplicated diverticulitis: does it work?
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2014 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 49, no 12, p. 1441-1446Article in journal (Refereed) Published
Abstract [en]

Background. The first randomized multicenter study evaluating the need for antibiotic treatment in patients with acute uncomplicated diverticulitis (AUD) could not demonstrate any benefit gained from antibiotic use. The aim of this study was to review the application of the no antibiotic policy and its consequences in regard to complications and recurrence. Methods. This retrospective population-based cohort study included all patients diagnosed with all types of colonic diverticulitis during the year 2011 at Vastmanland Hospital Vasteras, Sweden. All medical records were carefully reviewed. Primary outcomes were the types of treatment adopted for diverticulitis, complications and recurrence. Results. In total, 246 patients with computer tomography-verified diverticulitis were identified, 195 with primary AUD and 51 with acute complicated diverticulitis. Age, sex, and temperature at admission were similar between the groups but there was a significant difference in white blood cell count, C-reactive protein, and length of hospital stay. In the AUD group, 178 (91.3%) patients were not treated with antibiotics. In this group, there were six (3.4%) readmissions but only two developed an abscess. Of the remaining 17 patients (8.7%) who were treated with antibiotics in the AUD group, one developed an abscess. Twenty-five (12.8%) patients in the AUD group presented with a recurrence within 1 year. Conclusion. The no-antibiotic policy for AUD is safe and applicable in clinical practice. The previous results of a low complication and recurrence rate in AUD are confirmed. There is no need for antibiotic treatment for AUD. What does this paper add to the literature? Despite published papers with excellent results, there are still doubts about patient safety against the policy to not use antibiotics in acute uncomplicated diverticulitis. This is the first paper, in actual clinical practice, to confirm that the no antibiotic policy for acute uncomplicated diverticulitis is applicable and safe.

Keywords
antibiotics, colonic diverticulitis, complications
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:uu:diva-240083 (URN)10.3109/00365521.2014.968861 (DOI)000345603500007 ()25369865 (PubMedID)
Available from: 2015-01-05 Created: 2015-01-05 Last updated: 2018-12-10Bibliographically approved
2. Antibiotic avoidance in patients with acute uncomplicated diverticulitis: ten-year follow-up of a randomized clinical trial
Open this publication in new window or tab >>Antibiotic avoidance in patients with acute uncomplicated diverticulitis: ten-year follow-up of a randomized clinical trial
(English)In: Article in journal (Refereed) Submitted
Keywords
Diverticulitis, antibiotics, recurrent diverticulitis, sigmoidectomy
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-369127 (URN)
Available from: 2018-12-10 Created: 2018-12-10 Last updated: 2018-12-20
3. Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study
Open this publication in new window or tab >>Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study
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2015 (English)In: International Journal of Colorectal Disease, ISSN 0179-1958, E-ISSN 1432-1262, Vol. 30, no 9, p. 1229-1234Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to evaluate outpatient, non-antibiotic management in acute uncomplicated diverticulitis with regard to admissions, complications, and recurrences, within a 3-month follow-up period. A prospective, observational study in which patients with computer tomography-verified acute uncomplicated diverticulitis were managed as outpatients without antibiotics. The patients kept a personal journal, were contacted daily by a nurse, and then followed up by a surgeon at 1 week and 3 months. In total, 155 patients were included, of which 54 were men; the mean age of the patients was 57.4 years. At the time of diagnosis, the mean C-reactive protein and white blood cell count were 73 mg/l and 10.5 x 10(9), respectively, and normalized in the vast majority of patients within the first week. The majority of the patients (97.4 %) were managed successfully as outpatients without antibiotics, admissions, or complications. In only four (2.6 %) patients, the management failed because of complications in three and deterioration in one. These patients were all treated successfully as inpatients without surgery. Five patients had recurrences and were treated as outpatients without antibiotics. Follow-up colonic investigations revealed cancer in two patients and polyps in 13 patients. Previous results of low complication rates with the non-antibiotic policy were confirmed. The new policy of outpatient management without antibiotics in acute uncomplicated diverticulitis is now shown to be feasible, well functioning, and safe.

Keywords
Diverticulitis, Outpatient management, Antibiotics
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-262965 (URN)10.1007/s00384-015-2258-y (DOI)000360542000011 ()25989930 (PubMedID)
Note

Correction in: International Journal of Colorectal Disease, 2015, vol. 30, issue 9, pages 1225-1235, doi: 10.1007/s00384-015-2284-9

Available from: 2015-09-24 Created: 2015-09-23 Last updated: 2018-12-10Bibliographically approved
4. Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings
Open this publication in new window or tab >>Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings
Show others...
2018 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 53, no 4, p. 449-452Article in journal (Refereed) Published
Abstract [en]

Purpose:

Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics.

Methods:

The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Vastmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model.

Results:

In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p<.001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p<.001). The total health-care cost was Euro558,679 in 2011 compared with Euro370,370 in 2014 (p<.001). Three patients developed complications in 2011 and four in 2014 (p=.469).

Conclusions:

The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

Keywords
Diverticulitis, outpatient management, antibiotics, health-care costs
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:uu:diva-354262 (URN)10.1080/00365521.2018.1448887 (DOI)000430726600011 ()29543100 (PubMedID)
Available from: 2018-06-28 Created: 2018-06-28 Last updated: 2018-12-10Bibliographically approved

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