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Comparative effectiveness and harms of a combination of Metronidazole and a fluoroquinolone or Amoxicillin – Clavulanate alone for outpatient diverticulitis


Outpatient diverticulitis is commonly treated with either a combination of Metronidazole and a fluoroquinolone ( Metronidazole-with-fluoroquinolone ) or Amoxicillin – Clavulanate ( Augmentin ) alone.

The FDA ( U.S. Food and Drug Administration ) has 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.

The objective is to determine the effectiveness and harms of Metronidazole-with-fluoroquinolone versus Amoxicillin–Clavulanate for outpatient diverticulitis, in two cohorts.
The first included U.S. residents aged 18 to 64 years in the IBM MarketScan Commercial Claims and Encounters Database ( n = 119,521 ), and the second included Medicare patients aged 65 years or older between 2006 and 2015 ( n = 20,348 ).

The measurements were: 1-year risks for inpatient admission, urgent surgery, and Clostridioides difficile infection ( CDI ) and 3-year risk for elective surgery.

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 ] ).

In conclusion, treating diverticulitis in the outpatient setting with Amoxicillin – Clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes. ( Xagena )

Gaber CE et al, Ann Intern Med 2021;doi:10.7326/M20-6315.

XagenaMedicine_2021



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