From the Guidelines
In immunocompetent patients with uncomplicated acute diverticulitis, antibiotics should not be prescribed as a routine treatment. This recommendation is based on high-quality evidence from the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1. The guidelines suggest that uncomplicated acute diverticulitis may be a self-limiting condition in which local host defenses can manage the inflammation without antibiotics in immunocompetent patients.
Key Points to Consider
- Uncomplicated acute diverticulitis is defined as localized diverticular inflammation without any abscess or perforation 1.
- The utility of antibiotics in acute uncomplicated diverticulitis has been a point of controversy, but recent studies have demonstrated that antimicrobial treatment is not superior to withholding antibiotic therapy in terms of clinical resolution 1.
- A multicenter randomized trial published in 2012 by Chabok et al. found that antibiotic treatment for acute uncomplicated diverticulitis neither accelerated recovery nor prevented complications or recurrence 1.
- The current consensus is that antibiotics should be reserved for the treatment of complicated diverticulitis, and can be used selectively in immunocompetent patients with mild uncomplicated diverticulitis 1.
Treatment Approach
- For mild cases of uncomplicated diverticulitis, symptomatic treatment without antibiotics may be sufficient, with a focus on rest, pain management, and dietary modifications.
- Severe cases may require hospitalization for IV antibiotics, bowel rest, and possibly surgery.
- To prevent recurrence, maintaining a high-fiber diet, staying well-hydrated, exercising regularly, and avoiding smoking are recommended.
From the Research
Treatment of Diverticulitis
- The treatment of diverticulitis has become more conservative over the years, with a focus on outpatient treatment and the use of oral antibiotics 2.
- Uncomplicated diverticulitis can be treated without antibiotics, without bed rest, and without dietary restrictions, and a selected group of patients can be treated as outpatients 3.
- The use of antibiotics in uncomplicated diverticulitis is questionable, as the condition may be inflammatory rather than infectious 4.
Antibiotic Treatment
- The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications 4.
- A study comparing ceftriaxone and metronidazole to piperacillin/tazobactam in patients with complicated diverticulitis found that ceftriaxone and metronidazole was non-inferior to piperacillin/tazobactam for the combined primary outcome of 30-day readmission or all-cause mortality 5.
- Another study found that patients who received oral antibiotic therapy in the 7 days prior to admission were found to have increased risk of mortality or readmission and antibiotic failure 5.
Outpatient Treatment
- Outpatient treatment with oral antibiotics is a safe and effective option for patients with uncomplicated diverticulitis who are able to tolerate oral intake and have adequate family support 2.
- A study found that ambulatory treatment of uncomplicated acute diverticulitis was completed without complication in 97% of patients 2.
Patient Subgroups
- Patients on immunosuppression or non-steroidal anti-inflammatory drugs may have a higher risk of complicated diverticulitis 3.
- Young patients do not seem to have a higher risk of complicated diverticulitis, and the risk of recurrent diverticulitis in young patients is comparable to elderly patients 3.