Physicians attempt to prescribe antibiotics as little as possible, due to their potential to cause the bacterial infection C. diff, as well as their ability to promote drug resistance in the body. But in acute cases of diverticulitis — an inflammation of small pockets in the colon — patients are often prescribed antibiotics, even though recent guidelines from the American Society of Colon and Rectal Surgeons and the American Gastroenterology Association say they aren’t necessary in cases where there are no additional complications.
“We want to be judicious with antibiotics and only use them when it's appropriate,” says Janet Lee, MD, a former general surgery resident in the University of Colorado Anschutz Department of Surgery. “There have been multiple European studies demonstrating antibiotics can be safely omitted in healthy adults with acute uncomplicated sigmoid diverticulitis.”
While she was a resident in the CU Department of Surgery, Lee worked with Jon Vogel, MD, professor in the Division of GI, Trauma, and Endocrine Surgery, on a project to reduce antibiotic use in acute diverticulitis cases in the emergency room (ER) at the UCHealth University of Colorado Hospital. By providing education on the new guidelines to providers in the ER, as well as creating a clinical pathway in the electronic health record that providers could follow to determine which patients didn’t need antibiotics, Vogel, Lee, and their fellow researchers significantly reduced the use of antibiotics in eligible patients.
“Historically, it was thought that diverticulitis was related to bacterial infection, so it was treated with antibiotics,” says Lee, now a fellow in colon and rectal surgery at the University of Minnesota. “Although there are multiple studies from Europe demonstrating that it’s OK just to provide symptom management, and now the American Society of Colorectal Surgeons and American Gastroenterology Association have guidelines saying that patients with acute, uncomplicated sigmoid diverticulitis can be treated without antibiotics, the use of antibiotics is still very prevalent in the United States. Uptake of the guidelines has been slow.”
Over a 25-month study period, however, Lee and Vogel oversaw a drop in antibiotic use in qualified patients at UCHealth University of Colorado Hospital — from 100% of qualifying patients receiving antibiotics prior to the intervention to 60% by its end.
“Going from 100% to 60% was good, but it could be better. There's definitely room for improvement,” Lee says. “We conducted this intervention only at Anschutz, which was a good starting point, but in March of this year, we expanded this protocol systemwide, so all UCHealth emergency departments now use this protocol. For the next study, we want to look at outcomes in a bigger patient sample.”
The most novel and replicable part of the project, Lee says, was using the electronic health record to reinforce the recommendations.
“Our emergency medicine physicians frequently use EHR-integrated clinical pathways to deliver evidence-based, standardized care. We used this functionality to implement a diverticulitis clinical pathway within our EHR. The pathway guides providers on which patients are appropriate for symptom-based management with Tylenol or NSAIDs and which patients should be excluded,” she says. “There's so much we can do in the EHR to make sure that patient care aligns with guideline-concordant care.”
Vogel plans to continue to study the issue and to educate ER and other providers on the antibiotic guidelines for diverticulitis.
"Continued antibiotic treatment of uncomplicated diverticulitis is a puzzling issue for me,” Vogel says. “Despite an abundance of strong evidence against their use in this setting and clinical practice guidelines that endorse selective rather than broad use of antibiotics, most patients are still prescribed antibiotics. This is a concerning issue, as antibiotics have a cost and potential adverse effects, and may result in antibiotic resistance."