What is the management of acute diverticulitis in an afebrile patient?

From the Guidelines

For the management of acute uncomplicated diverticulitis in an afebrile patient, antibiotics are not recommended in immunocompetent patients without signs of systemic inflammation, as evidenced by high-quality studies 1. The approach to managing acute uncomplicated diverticulitis has evolved, with a focus on selective use of antibiotics.

Key Considerations

• The definition of uncomplicated acute diverticulitis is crucial, referring to localized diverticular inflammation without any abscess or perforation.
• Recent studies, including a multicenter randomized trial 1, have demonstrated that antibiotic treatment does not accelerate recovery, prevent complications, or reduce recurrence in immunocompetent patients with mild unperforated diverticulitis.
• The current consensus, as outlined in the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis 1, is that uncomplicated acute diverticulitis may be a self-limiting condition in which local host defenses can manage the inflammation without antibiotics in immunocompetent patients.

Management Approach

• Outpatient treatment without antibiotics is recommended for immunocompetent patients with uncomplicated diverticulitis, focusing on dietary modifications and pain management.
• Dietary modifications should include an initial clear liquid diet for 2-3 days, followed by a gradual advancement to a low-fiber diet until symptoms resolve, before slowly reintroducing fiber.
• Pain can be managed with acetaminophen (650-1000 mg every 6 hours as needed) or, if necessary, NSAIDs like ibuprofen (400-600 mg every 6 hours).
• Patients should be advised to seek immediate medical attention if they develop fever, increased pain, inability to tolerate oral intake, or other worsening symptoms.

Antibiotic Use

• Antibiotics are reserved for patients with complicated diverticulitis or those with uncomplicated diverticulitis who have comorbidities, are frail, present with refractory symptoms or vomiting, or have elevated CRP or white blood cell count, as suggested by the AGA clinical practice update 1.
• When antibiotic treatment is necessary, regimens usually include broad-spectrum agents with gram-negative and anaerobic coverage, such as amoxicillin-clavulanate or a combination of a fluoroquinolone and metronidazole.

From the Research

Acute Diverticulitis Management in Afebrile Patients

• The management of acute diverticulitis in afebrile patients typically involves outpatient treatment, as long as the patient is clinically stable and has uncomplicated diverticulitis 2, 3.
• Radiological evidence of inflammation, using computed tomography (CT), is necessary to diagnose the first occurrence of diverticulitis and to classify it as complicated or uncomplicated 2.
• For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 2, 4.
• Outpatient treatment with oral antibiotics, such as amoxicillin-clavulanic acid or ciprofloxacin plus metronidazole, can be effective in managing uncomplicated acute diverticulitis 3, 5.
• A study comparing metronidazole-with-fluoroquinolone to amoxicillin-clavulanate for outpatient diverticulitis found no differences in 1-year risks for inpatient admission, urgent surgery, or elective surgery, but a higher risk of Clostridioides difficile infection with metronidazole-with-fluoroquinolone 5.

Treatment Options

• Outpatient treatment is recommended for afebrile, clinically stable patients with uncomplicated diverticulitis 2, 3.
• Antibiotics, such as amoxicillin-clavulanic acid, can be used to treat uncomplicated diverticulitis, but their use should be selective and based on individual patient needs 2, 4.
• Rifaximin has been shown to be effective in obtaining symptom relief and improving symptoms in patients with uncomplicated diverticular disease 6.
• Percutaneous drainage may be necessary for larger abscesses, and surgical intervention may be required for peritonitis or failure of non-operative management 2.

Follow-up and Monitoring

• Patients with complicated diverticulitis should undergo colonoscopy 6 weeks after CT diagnosis of inflammation 2.
• Patients with uncomplicated diverticulitis who have suspicious features on CT scan or who meet national bowel cancer screening criteria should also undergo colonoscopy 2.