Antibiotics versus No Antibiotics for the Treatment of Acute Uncomplicated Diverticulitis: Review of the Evidence and Future Directions

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Abstract

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 37th 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.

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Antibiotics vs. Appendectomy for Acute Uncomplicated Appendicitis in Adults: Review of the Evidence and Future Directions

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Abstract

Background: Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis.

Methods: Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial.

Results: According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship.

Conclusion: Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.

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Introduction to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infections

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Surgical site infection (SSI) is a common type of health-care–associated infection (HAI) and adds considerably to the individual, social, and economic costs of surgical treatment. This document serves to introduce the updated Guideline for the Prevention of SSI from the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The Core section of the guideline addresses issues relevant to multiple surgical specialties and procedures. The second procedure-specific section focuses on a high-volume, high-burden procedure: Prosthetic joint arthroplasty. While many elements of the 1999 guideline remain current, others warrant updating to incorporate new knowledge and changes in the patient population, operative techniques, emerging pathogens, and guideline development methodology.

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Introduction to the Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee Guideline for Prevention of Surgical Site Infection: Prosthetic Joint Arthroplasty Section

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Abstract

Peri-prosthetic joint infection (PJI) is a severe complication of total joint arthroplasty that appears to be increasing as more of these procedures are performed. Numerous risk factors for incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSIs) have been identified. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional SSI and PJI. The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recently updated the national Guideline for Prevention of Surgical Site Infection. The updated guideline applies evidence-based methodology, presents recommendations for potential strategies to reduce the risk of SSI, and includes an arthroplasty-specific section. This article serves to introduce the guideline development process and to complement the Prosthetic Joint Arthroplasty section with background information on PJI-specific economic burden, epidemiology, pathogenesis and microbiology, and risk factor information.

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Surgical Site Infection Research Opportunities

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Abstract

Much has been done to identify measures and modify risk factors to decrease the rate of surgical site infection (SSI). Development of the Centers for Disease Control and Prevention (CDC) Core recommendations for the prevention of SSI revealed evidence gaps in six areas: Parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, antiseptic prophylaxis, and non-parenteral antimicrobial prophylaxis. Using a modified Delphi process, seven SSI content experts identified nutritional status, smoking, obesity, surgical technique, and anemia as additional areas for SSI prevention research. Post-modified Delphi process Staphylococcus aureus colonization and SSI definition and surveillance were also deemed important topic areas for inclusion. For each topic, research questions were developed, and 10 were selected as the final SSI research questions.

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Executive Summary of the American College of Surgeons/Surgical Infection Society Surgical Site Infection Guidelines—2016 Update

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Abstract

Guidelines regarding the prevention, detection, and management of surgical site infections (SSIs) have been published previously by a variety of organizations. The American College of Surgeons (ACS)/Surgical Infection Society (SIS) Surgical Site Infection (SSI) Guidelines 2016 Update is intended to update these guidelines based on the current literature and to provide a concise summary of relevant topics.

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The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

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Abstract

Background: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

Methods: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

Results: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

Summary: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

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The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

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Abstract

Background: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

Methods: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

Results: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

Summary: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

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