Amoxicillin-clavulanate safe, effective for uncomplicated diverticulitis


By Lisa Rapaport

(Reuters Health) - Patients with uncomplicated diverticulitis who are treated in the outpatient setting with amoxicillin-clavulanate may avoid the infection risk associated with fluoroquinolone while achieving similar diverticulitis-related outcomes, a new study suggests.

Researchers examined claims data for U.S. patients with private insurance or Medicare who were treated for diverticulitis in the outpatient setting between 2006 and 2015 with either metronidazole and a fluoroquinolone, or with amoxicillin-clavulanate.

Among those with private insurance, there wasn't a significant difference between patients prescribed metronidazole and fluoroquinolone (n=106,361) and those prescribed amoxicillin-clavulanate (n=13,160) in 1-year admission risk (difference 0.1 percentage points), 1-year urgent surgery risk (difference 0.0 percentage points), 1-year elective surgery risk (difference 0.2 percentage points), or 1-year risk of Clostridioides difficile infection (difference 0.0 percentage points).

And, among those with Medicare, there wasn't a significant difference between patients prescribed metronidazole and fluoroquinolone (n=17,639) and those prescribed amoxicillin-clavulanate (n=2,709) in 1-year admission risk (difference 0.1 percentage points), 1-year urgent surgery risk (difference -0.2 percentage points), or 3-year elective surgery risk (difference -0.3) percentage points. In this cohort, the 1-year risk of Clostridioides difficile infection was higher with metronidazole and fluoroquinolone (difference 0.6 percentage points).

"Physicians should consider treating outpatient diverticulitis with amoxicillin-clavulanate, instead of metronidazole with a fluoroquinolone," said senior study author Dr. Anne Peery, an associate professor of medicine at the University of North Carolina-Chapel Hill.

"This approach has the potential to reduce the risk for fluoroquinolone-related harms, including Clostridioides difficile infection, without adversely affecting diverticulitis outcomes," Dr. Peery said by email.

In addition to infection, other risks associated with fluoroquinolone use in other studies include low blood sugar, mental health effects, peripheral neuropathy, aortic dissection, aneurysm, and adverse effects to tendons, muscles, joints, and nerves, Dr. Peery said.

Because the U.S Food and Drug Administration recommends fluoroquinolone use only in conditions with no alternative treatment, the current study results suggest that this antibiotic may no longer be necessary for many patients with diverticulitis who can take amoxicillin-clavulanate instead, Dr. Peery added.

One limitation of the study, the authors note in Annals of Internal Medicine, is that they lacked data on some potential harms associated with antibiotics, including drug-induced liver injury.

"This is the first study that I am aware of to compare directly amoxicillin-clavulanate to metronidazole-fluoroquinolone for uncomplicated diverticulitis," said Dr. Lisa Strate, a professor of medicine at Harborview Medical Center and the University of Washington School of Medicine, in Seattle, who wasn't involved in the study.

Clinicians should also consider carefully whether antibiotics are indicated at all, Dr. Strate said by email.

"To me, the take-home message for clinicians is to pause before prescribing any antibiotics for diverticulitis and take the time to discuss the data, risks and benefits with each patient," Dr. Strate added. "If prescribing antibiotics for uncomplicated diverticulitis, consider amoxicillin-clavulanate as frontline therapy, and in general, carefully consider the side effect profiles of antibiotics."

SOURCE: Annals of Internal Medicine, online February 22, 2021.

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