Citation
Gaber, Charles E.; Kinlaw, Alan C.; Edwards, Jessie K.; Lund, Jennifer L.; Stürmer, Til; Peacock Hinton, Sharon; Pate, Virginia; Bartelt, Luther A.; Sandler, Robert S.; & Peery, Anne F. (2021). Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies. Annals of Internal Medicine, 174(6), 737-746. PMCID: PMC9035276Abstract
BACKGROUND: Outpatient diverticulitis is commonly treated with either a combination of metronidazole and a fluoroquinolone (metronidazole-with-fluoroquinolone) or amoxicillin-clavulanate alone. The U.S. Food and Drug Administration advised that fluoroquinolones be reserved for conditions with no alternative treatment options. The comparative effectiveness of metronidazole-with-fluoroquinolone versus amoxicillin-clavulanate for diverticulitis is uncertain.OBJECTIVE: To determine the effectiveness and harms of metronidazole-with-fluoroquinolone versus amoxicillin-clavulanate for outpatient diverticulitis.
DESIGN: Active-comparator, new-user, retrospective cohort studies.
SETTING: Nationwide population-based claims data on U.S. residents aged 18 to 64 years with private employer-sponsored insurance (2000 to 2018) or those aged 65 years or older with Medicare (2006 to 2015).
PARTICIPANTS: Immunocompetent adults with diverticulitis in the outpatient setting.
INTERVENTION: Metronidazole-with-fluoroquinolone or amoxicillin-clavulanate.
MEASUREMENTS: 1-year risks for inpatient admission, urgent surgery, and Clostridioides difficile infection (CDI) and 3-year risk for elective surgery.
RESULTS: In MarketScan (IBM Watson Health), new users of metronidazole-with-fluoroquinolone (n = 106 361) and amoxicillin-clavulanate (n = 13 160) were identified. There were no differences in 1-year admission risk (risk difference, 0.1 percentage points [95% CI, -0.3 to 0.6]), 1-year urgent surgery risk (risk difference, 0.0 percentage points [CI, -0.1 to 0.1]), 3-year elective surgery risk (risk difference, 0.2 percentage points [CI, -0.3 to 0.7]), or 1-year CDI risk (risk difference, 0.0 percentage points [CI, -0.1 to 0.1]) between groups. In Medicare, new users of metronidazole-with-fluoroquinolone (n = 17 639) and amoxicillin-clavulanate (n = 2709) were identified. There were no differences in 1-year admission risk (risk difference, 0.1 percentage points [CI, -0.7 to 0.9]), 1-year urgent surgery risk (risk difference, -0.2 percentage points [CI, -0.6 to 0.1]), or 3-year elective surgery risk (risk difference, -0.3 percentage points [CI, -1.1 to 0.4]) between groups. The 1-year CDI risk was higher for metronidazole-with-fluoroquinolone than for amoxicillin-clavulanate (risk difference, 0.6 percentage points [CI, 0.2 to 1.0]).
LIMITATION: Residual confounding is possible, and not all harms associated with these antibiotics, most notably drug-induced liver injury, could be assessed.
CONCLUSION: Treating diverticulitis in the outpatient setting with amoxicillin-clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes.
URL
http://dx.doi.org/10.7326/M20-6315Reference Type
Journal ArticleYear Published
2021Journal Title
Annals of Internal MedicineAuthor(s)
Gaber, Charles E.Kinlaw, Alan C.
Edwards, Jessie K.
Lund, Jennifer L.
Stürmer, Til
Peacock Hinton, Sharon
Pate, Virginia
Bartelt, Luther A.
Sandler, Robert S.
Peery, Anne F.
Article Type
RegularPMCID
PMC9035276Continent/Country
United States of AmericaState
NonspecificRace/Ethnicity
WhiteBlack
Hispanic/Latinx
Asian