Discharging patients with uncomplicated diverticulitis from the emergency department on antibiotics was just as effective as hospitalization – and cost about a third as much, based on a study conducted in Spain.
Dr. Sebastiano Biondi and his colleagues conducted their randomized, parallel-group study at five hospitals. The cohort consisted of 132 adults, mean age 56 years, who presented to the emergency department with localized abdominal pain. All had an abdominal CT scan and received intravenous antibiotics, either an initial IV infusion of 1 g of amoxicillin per 125 mg of clavulanic acid, or, in the case of those with a penicillin allergy, ciprofloxacin 200 mg and metronidazole 500 mg.
Half of the patients were then assigned to either inpatient or outpatient antibiotic treatment. The admitted patients continued to receive IV antibiotics and fluids for 36-48 hours until they tolerated oral feeding. The outpatients were discharged on oral amoxicillin and clavulanic acid (875 mg per 125 mg every 8 hours) or, in those with penicillin allergy, the combination of ciprofloxacin (500 mg every 12 hours) and metronidazole (500 mg every 8 hours).
The study’s main endpoint was treatment failure rate (persistence, increase, or recurrence of abdominal pain and/or fever; inflammatory bowel obstruction; or the need for radiological abscess drainage or immediate surgery due to complicated diverticulitis). Patients were followed every day for 5 days, and then interviewed on day 14. Before the final follow-up at 60 days, patients underwent a colonoscopy to rule out malignancy.
Seven patients (5%) were readmitted due to treatment failure: 4 (6%) in the inpatient group and three (4.5%) in the outpatient group. The difference was not statistically significant. No one needed emergency surgery as part of readmission, and there were no deaths.
A quality of life assessment found that hospitalized patients reported a significantly higher level of physical health during the first 2 weeks of treatment, but that difference disappeared after 14 days.
Total treatment costs were significantly less in the outpatient group, with an average savings of $1,840 per patient ($895 for outpatient care compared with $2,735 for inpatient care). Almost all of that cost difference was due to hospital bed cost, with an average stay of 4 days.
"The outpatient protocol of this study is applicable to a selected group of patients with uncomplicated diverticulitis," Dr. Biondi reported in the January issue of Annals of Surgery (doi: 10.1097/SLA.0b013e3182965a11).
Widespread adoption of outpatient treatment could have a profound effect on the cost of treating diverticulitis, an ever more common gastrointestinal problem, said Dr. Biondi of the University of Barcelona and his coauthors. "According to data from the National Hospital Discharge Survey, diverticular disease is responsible for 314,000 hospital admissions per year in the United States, and the estimated annual cost in 1998 was about $2.6 billion."
The Spanish Ministry of Health funded the trial. The authors had no financial conflicts.
