NHG-Standaard Diverticulitis

A scoping review of evidence-based guidance and guidelines published by general practice professional organizations

BACKGROUND

General practitioners (GPs) need robust, up-to-date evidence to deliver high-quality patient care. There is limited literature regarding the role of international GP professional organizations in developing and publishing clinical guidelines to support GPs clinical decision making.

OBJECTIVE

To identify evidence-based guidance and clinical guidelines produced by GP professional organizations and summarize their content, structure, and methods of development and dissemination.

METHODS

Scoping review of GP professional organizations following Joanna Briggs Institute guidance. Four databases were searched and a grey literature search was conducted. Studies were included if they were: (i) evidence-based guidance documents or clinical guidelines produced de novo by a national GP professional organization, (ii) developed to support GPs clinical care, and (iii) published in the last 10 years. GP professional organizations were contacted to provide supplementary information. A narrative synthesis was performed.

RESULTS

Six GP professional organizations and 60 guidelines were included. The most common de novo guideline topics were mental health, cardiovascular disease, neurology, pregnancy and women's health and preventive care. All guidelines were developed using a standard evidence-synthesis method. All included documents were disseminated through downloadable pdfs and peer review publications. GP professional organizations indicated that they generally collaborate with or endorse guidelines developed by national or international guideline producing bodies.

CONCLUSION

The findings of this scoping review provide an overview of de novo guideline development by GP professional organizations and can support collaboration between GP organizations worldwide thus reducing duplication of effort, facilitating reproducibility, and identifying areas of standardization.

PROTOCOL REGISTRATION

Open Science Framework: https://doi.org/10.17605/OSF.IO/JXQ26.

C-reactive protein point-of-care testing in primary care-broader implementation needed to combat antimicrobial resistance

This study presents the perspective of an international group of experts, providing an overview of existing models and policies and guidance to facilitate a proper and sustainable implementation of C-reactive protein point-of-care testing (CRP POCT) to support antibiotic prescribing decisions for respiratory tract infections (RTIs) with the aim to tackle antimicrobial resistance (AMR). AMR threatens to render life-saving antibiotics ineffective and is already costing millions of lives and billions of Euros worldwide. AMR is strongly correlated with the volume of antibiotics used. Most antibiotics are prescribed in primary care, mostly for RTIs, and are often unnecessary. CRP POCT is an available tool and has been proven to safely and cost-effectively reduce antibiotic prescribing for RTIs in primary care. Though established in a few European countries during several years, it has still not been implemented in many European countries. Due to the complexity of inappropriate antibiotic prescribing behavior, a multifaceted approach is necessary to enable sustainable change. The effect is maximized with clear guidance, advanced communication training for primary care physicians, and delayed antibiotic prescribing strategies. CRP POCT should be included in professional guidelines and implemented together with complementary strategies. Adequate reimbursement needs to be provided, and high-quality, and primary care-friendly POCT organization and performance must be enabled. Data gathering, sharing, and discussion as incentivization for proper behaviors should be enabled. Public awareness should be increased, and healthcare professionals' awareness and understanding should be ensured. Impactful use is achieved when all stakeholders join forces to facilitate proper implementation.

Accuracy of diagnostic tests for acute diverticulitis that are feasible in primary care: a systematic review and meta-analysis

BACKGROUND

Recognition of acute diverticulitis is important to determine an adequate management strategy. Differentiating it from other gastrointestinal disorders is challenging as symptoms overlap. Clinical tests might assist the clinician with this diagnostic challenge. Previous reviews have focussed on prognostic questions and imaging examinations in secondary care.

OBJECTIVE

To evaluate the diagnostic accuracy of clinical tests feasible in primary care for acute diverticulitis in suspected patients.

METHOD

We have systematically searched multiple databases for diagnostic accuracy studies of tests feasible in primary care compared to a reference standard in suspected patients. Two reviewers independently selected studies, extracted data, and assessed study quality with the QUADAS-2 tool. We have meta-analysed the results in the case of more than four studies per index test.

RESULTS

Seventeen studies were included, all studies were performed in secondary care (median prevalence 48%). Individual signs and symptoms showed a wide range in sensitivity (range 0.00-0.98) and specificity (range 0.08-1.00). Of the four laboratory tests evaluated, CRP >10 mg/l had the highest sensitivity (range 0.89-0.96) with specificity ranging from 0.28 to 0.61. Ultrasound had the highest pooled sensitivity and specificity of 0.92 (95% CI 0.86-0.96) and 0.94 (95% CI 0.88-0.97), respectively.

CONCLUSION

None of the studies were performed in primary care. Individual signs and symptoms alone are insufficiently informative for acute diverticulitis diagnosis. CRP showed potential for ruling out and ultrasound had a high diagnostic accuracy. More research is needed about the diagnostic accuracy of these tests in primary care.

PROSPERO REGISTRATION NUMBER

CRD42021230622.

Giant colonic diverticulum: case report of a rare surgical condition

INTRODUCTION

Diverticular disease is a common disorder of the colon with an extremely rare presentation: giant colonic diverticulum (GCD). GCD is defined as a diverticulum measuring 4 cm or larger and affects the sigmoid colon in 90% of the cases.

PATIENTS

We report on a case of a 74-year-old woman with a GCD.

METHODS

We present a case report of a 74-year-old woman with a GCD. A brief review of the literature concerning clinical presentation, diagnosis, differential diagnosis, pathogenesis, histological classification and treatment of GCD will be discussed.

RESULTS

Our patient was treated according to the available information in the literature. The outcome was uneventful.

CONCLUSIONS

GCD is a rare presentation of diverticular disease. Because of the risk of serious complications, a correct diagnosis and treatment is essential. The investigations of choice include a plain abdominal X-ray and an abdominal CT scan. Surgical treatment is the treatment of choice with preferably a colectomy with en-bloc resection of the diverticulum.

Clinical factors, C-reactive protein point of care test and chest X-ray in patients with pneumonia: A survey in primary care

Background: In patients with an acute lower respiratory tract infection (LRTI), general practitioners (GPs) often find it challenging to decide to prescribe antibiotics or not. C-reactive protein (CRP) point of care test (POCT), and chest X-ray are diagnostic tests that can optimize the treatment decision. However, their usefulness in clinical practice is unknown.

Objectives: To determine the proportion of Dutch GPs using CRP and chest X-ray in patients with an acute LRTI. To determine whether clinical factors and C-reactive protein point of care test affect the behaviour in requesting chest X-rays.

Methods: In 2014, a questionnaire was sent to a random sample of 900 Dutch GPs. Outcome parameters are the use of CRP and chest X-ray, the percentage of GPs who guide their decision in requesting chest X-rays by CRP testing and the GP’s expectation regarding presence or absence of pneumonia. In addition, considerations for requesting chest X-rays were assessed.

Results: Two hundred and fifty-five completed questionnaires (29%) were returned. In 2014, 54% of the responding GPs used the CRP test. These GPs tend to use fewer chest X-rays (p = 0.07). GPs overestimate the chance that pneumonia will be present on the radiograph. Seventy percent consider the possibility of abnormalities other than pneumonia as the main reason for requesting a chest X-ray.

Conclusion: In patients with an acute lower respiratory tract infection, GPs report that CRP results affect their behaviour regarding the request of a chest X-ray in patients with lower respiratory tract infection and therefore research is needed to substantiate the use of these diagnostic tools for this purpose.

Development and validation of a diagnostic prediction model distinguishing complicated from uncomplicated diverticulitis

OBJECTIVES

Most diverticulitis patients (80%) who are referred to secondary care have uncomplicated diverticulitis (UD) which is a self-limiting disease and can be treated at home. The aim of this study is to develop a diagnostic model that can safely rule out complicated diverticulitis (CD) based on clinical and laboratory parameters to reduce unnecessary referrals.

METHODS

A retrospective cross-sectional study was performed including all patients who presented at the emergency department with CT-proven diverticulitis. Patient characteristics, clinical signs and laboratory parameters were collected. CD was defined as > Hinchey 1A. Multivariable logistic regression analyses were used to quantify which (combination of) variables were independently related to the presence or absence of CD. A diagnostic prediction model was developed and validated to rule out CD.

RESULTS

A total of 943 patients were included of whom 172 (18%) had CD. The dataset was randomly split into a derivation and validation set. The derivation dataset contained 475 patients of whom 82 (18%) patients had CD. Age, vomiting, generalized abdominal pain, change in bowel habit, abdominal guarding, C-reactive protein and leucocytosis were univariably related to CD. The final validated diagnostic model included abdominal guarding, C-reactive protein and leucocytosis (AUC 0.79 (95% CI 0.73-0.84)). At a CD risk threshold of ≤7.5% this model had a negative predictive value of 96%.

CONCLUSION

This proposed prediction model can safely rule out complicated diverticulitis. Clinical practitioners could cautiously use this model to aid them in the decision whether or not to subject patients to further secondary care diagnostics or treatment.

Influence of point-of-care C-reactive protein testing on antibiotic prescription habits in primary care in the Netherlands

BACKGROUND

Bacterial resistance to antibiotics represents a serious global challenge that is associated with high morbidity and mortality. One of the most important causes of this threat is antibiotic overuse. The Dutch College of General Practitioners (DCGP) recommends the use of point-of-care (POC) testing for C-reactive protein (CRP) in two guidelines ('Acute Cough' and 'Diverticulitis') to achieve a more sensible prescription pattern of antibiotics.

OBJECTIVE

To evaluate the use of POC-CRP testing in light of the DCGP guidelines and the effect of CRP measurements on antibiotic prescription policy in primary care.

METHODS

In a prospective observational study, which included 1756 patients, general practitioners (GPs) were asked to complete a questionnaire after every POC-CRP testing, stating the indication for performing the test, the CRP result and their decision whether or not to prescribe antibiotics. Indications were verified against the DCGP guidelines and categorized. Antibiotic prescription was evaluated in relation to CRP concentrations.

RESULTS AND CONCLUSION

Indications to perform POC-CRP test and the prescription pattern of antibiotics based on CRP value varied considerably between GPs. Differences in antibiotic prescription rate were most obvious in patients who presented with CRP values between 20 and 100 mg/l, and could in part be explained by the indication for performing POC-CRP test and patient age. Most GPs followed the DCGP guidelines and used low CRP values to underpin their decision to refrain from antibiotic prescription. Peer-based reflection on differences in POC-CRP usage and antibiotic prescription rate amongst GPs may further nourish a more critical approach to prescription of antibiotics.

Risk factors for complicated diverticulitis: systematic review and meta-analysis

PURPOSE

The aim of this systematic review is to identify risk factors that can predict complicated diverticulitis. Uncomplicated diverticulitis is a self-limiting and mild disease, but 10% of patients with diverticulitis develop complications requiring further treatment. It is important to estimate the risk of developing complicated diverticulitis at an early stage to set the right treatment at initial presentation.

METHODS

Embase, MEDLINE, and Cochrane databases were searched for studies reporting on risk factors for complicated diverticulitis. Complicated diverticulitis was defined as Hinchey ≥Ib or severe diverticulitis according to the Ambrosetti criteria. Meta-analyses were performed when at least four studies reported on the outcome of interest. This study was conducted according to the PRISMA guidelines.

RESULTS

A total of 12 studies were included with a total of 4619 patients. Most were of reasonable quality. Only the risk factors "age" and "sex" were eligible for meta-analysis, but none showed a significant effect on the risk for complicated diverticulitis. There was reasonable quality of evidence suggesting that high C-reactive protein; white blood cell count; clinical signs including generalized abdominal pain, constipation and vomiting; steroid usage; a primary episode; and comorbidity are risk factors for complicated diverticulitis.

CONCLUSION

Although high-level evidence is lacking, this study identified several risk factors associated with complicated diverticulitis. Individually, these risk factors have little value in predicting the course of diverticulitis. The authors propose a prognostic model combining these risk factors which might be the next step to aid the physician in predicting the course of diverticulitis and setting the right treatment at initial presentation.