What is the management of acute diverticulitis with outpatient antibiotics (abx)?

From the Guidelines

Outpatient management of uncomplicated acute diverticulitis does not typically require antibiotics for immunocompetent patients with mild symptoms, as evidenced by the 2020 update of the WSES guidelines 1. The management of acute diverticulitis involves a comprehensive approach, considering the patient's overall health, symptoms, and potential complications.

• Patients with uncomplicated acute diverticulitis, without significant comorbidities, and able to manage themselves at home can be treated as outpatients, with a re-evaluation within 7 days from the time of diagnosis 1.
• The use of antibiotics in uncomplicated acute diverticulitis has been a topic of debate, with recent evidence suggesting that antibiotics may not be necessary in immunocompetent patients with mild symptoms 1.
• A systematic review and meta-analysis of 9 studies, including 2,505 patients with acute uncomplicated diverticulitis, found no difference in time to resolution or risk of readmission, progression to a complication, or need for surgery among patients treated with antibiotics compared to those not treated with antibiotics 1.
• The AGA clinical practice update on medical management of colonic diverticulitis recommends antibiotic treatment be used selectively, rather than routinely, in immunocompetent patients with mild uncomplicated diverticulitis 1.
• The recommended approach for outpatient management includes maintaining adequate hydration, initially following a clear liquid diet, gradually advancing to a low-fiber diet as symptoms improve, and then transitioning to a high-fiber diet after resolution.
• Patients should be instructed to seek immediate medical attention if they develop fever >101°F, severe abdominal pain, inability to tolerate oral intake, or signs of sepsis, and follow-up should occur within 2-3 days to ensure improvement.
• The DIVER trial demonstrated that outpatient treatment may be safe and effective in selected patients with uncomplicated acute diverticulitis, reducing costs without negatively influencing the quality of life of these patients 1.

From the Research

Acute Diverticulitis Management with Outpatient Antibiotics

• The management of acute diverticulitis with outpatient antibiotics is a common practice, with studies suggesting that it is safe and effective for patients with uncomplicated diverticulitis 2, 3, 4, 5.
• A study published in the Journal of Clinical Gastroenterology in 2016 found that antibiotics play a key role in the management of both uncomplicated and complicated diverticular disease, and that outpatient management is considered the best strategy in the majority of uncomplicated patients 2.
• Another study published in the Annals of Internal Medicine in 2021 compared the effectiveness and harms of metronidazole-with-fluoroquinolone versus amoxicillin-clavulanate for outpatient diverticulitis, and found that there were no differences in 1-year admission risk, 1-year urgent surgery risk, or 3-year elective surgery risk between the two groups 6.
• A systematic review and meta-analysis published in Techniques in Coloproctology in 2019 found that outpatient management of acute diverticulitis is safe and effective, with an overall failure rate of 4.3% (95% CI 2.6%-6.3%) 4.
• The use of oral antibiotics such as amoxicillin-clavulanic or ciprofloxacin plus metronidazole has been shown to be effective in treating uncomplicated acute diverticulitis in an outpatient setting 3, 5.

Patient Selection for Outpatient Management

• Patient selection is crucial for outpatient management of acute diverticulitis, with factors such as tolerance to oral intake, absence of severe comorbidities, and adequate family support being important considerations 3, 5.
• A study published in Colorectal Disease in 2010 found that ambulatory treatment of uncomplicated acute diverticulitis is safe and effective in patients with tolerance to oral intake and without severe comorbidities or inadequate family support 3.
• Another study published in Cirugia Espanola in 2006 found that ambulatory treatment of uncomplicated acute diverticulitis is applicable in most patients with tolerance to oral intake and an appropriate family environment 5.

Antibiotic Regimens for Outpatient Management

• The choice of antibiotic regimen for outpatient management of acute diverticulitis is important, with studies suggesting that amoxicillin-clavulanate may be a suitable alternative to metronidazole-with-fluoroquinolone 6.
• A study published in the Annals of Internal Medicine in 2021 found that treating diverticulitis in the outpatient setting with amoxicillin-clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 6.