SA204 - A Novel Nurse-led Clinic for Non-antibiotic Management of Acute Uncomplicated Diverticulitis: A Feasibility Study

Purpose/Background: Out-patient non-antibiotic treatment (NAT) of AUD for immunocompetent patients is safe and supported by ASCRS guidelines, however uptake in practice remains low. We hypothesize that a nurse-led outpatient NAT protocol for AUD is feasible.

Methods/Interventions: This prospective cohort study assessed the feasibility of a nurse-led outpatient NAT protocol that we developed at our institution for emergency department (ED) and family physicians to refer adults with suspected or confirmed AUD. Data were collected from inception (06/2022) to 08/2023. Inclusion criteria were immunocompetency, hemodynamic stability, lack of ileus, and CRP < 150mg/L. Patients with prior diverticulitis were included. Patients who were pregnant, peritonitic or lacked social support were referred to ED. Enrolled patients were managed according to a NAT protocol (analgesia and diet modification): 1) first appointment with a nurse by phone followed by blood tests and CT scan within 24 hours; 2) At least one in person visit within 24-48hrs with educational handouts given; 3) Referral to dietician for clear liquid to low residue diet; 4) Phone follow-up on days 3 & 7. Patients on antibiotics prior to referral continued their prescription. If symptoms persisted on day 7, patients were referred to colorectal surgery. In addition, we reviewed all eligible patients for treatment in the NAT clinic during the study period. Primary outcome was the success of the NAT protocol, defined as no ED visits or admissions within 60 days. Secondary outcomes were acceptability of referring physicians of NAT (proportion of patients referred to clinic without starting antibiotics as per protocol) and the proportion of eligible patients treated in the ED who received antibiotics.

Results/Outcomes: Overall, 128 patients were referred to clinic, of those, 48 had AUD, 73 had other diagnoses and 7 patients were not eligible (immunocompromise and pelvic abscess). Of 48 patients in clinic, 27 (56.2%) were treated with NAT, while the rest were started on antibiotics prior to referral. One patient treated by NAT was admitted for IV antibiotics for persistent symptoms and worsening inflammation on CT. No patients had recurrent symptoms within 60 days. Within the same period, 144 eligible patients were treated in ED. Clinic and ED groups had similar characteristics (Table 1). Patients treated in ED spent a mean of 10.3 hours (±SD 0.54). Antibiotics were started prior to referral in 43.8% (n=21) and 93.7% (n=135) in clinic and ED groups, respectively (p < 0.005). There was no difference in ED visits at 30 days (clinic 8.3% vs ED 12.8%, p=0.31) and no difference in hospital admissions (clinic 2.0% vs ED 4.1% p=0.5). Six patients in the ED group were admitted for persistent/increasing inflammation, pelvic abscess, bowel obstruction and C.difficile colitis.

Conclusion/Discussion: A novel out-patient nurse-led NAT protocol for AUD is feasible (92% success). The implementation of this NAT protocol streamlined AUD treatment and avoided ED visits, without compromising outcomes. The NAT clinic reduced antibiotic treatment by over half, when compared to ED managed AUD. Further physician and patient education is important to increase adoption of NAT for AUD.