Antibiotics versus no antibiotics for the treatment of acute uncomplicated diverticulitis: Review of the evidence and future directions

Background: Acute diverticulitis occurs in 25% of individuals with diverticular disease and is associated with significant morbidity and mortality rates. Disease severity is classified as uncomplicated or complicated, with the latter including perforation, fistula, obstruction, or distant abscess. Uncomplicated diverticulitis often improves without surgery or invasive therapies. Administration of antibiotics is a standard of care for treatment of acute uncomplicated diverticulitis. However, recent data suggest antibiotics do not influence outcomes significantly. To address these conflicting approaches, the Surgical Infection Society hosted an Update Symposium at its 37^th Annual Meeting examining the role of antibiotics in the treatment of acute uncomplicated diverticulitis. Here, we provide a synopsis of the symposium's findings and a brief review of recent prospective and randomized clinical trials on the topic. Methods: A search of Embase, MEDLINE, and the Cochrane Library was performed for prospective series and randomized clinical trials published between January 1, 2010, and January 1, 2018, comparing outcomes of antibiotic versus no antibiotic therapy for acute uncomplicated diverticulitis. Results: We identified two single-center prospective series and two randomized clinical trials comparing outcomes for patients with acute uncomplicated diverticulitis treated with antibiotics versus no antibiotics. Conclusion: Current evidence does not support administration of antibiotics to improve outcomes in carefully selected healthy patients with acute uncomplicated left-sided diverticulitis. Further studies should help identify specific subpopulations of patients who would derive benefit from antibiotic therapy and help define appropriate antibiotic regimens and treatment durations that minimize cost, adverse effects, and risk of anti-microbial resistance.