What is the treatment for diverticulitis (inflammation of the diverticula)?

From the Guidelines

Treatment for diverticulitis should be individualized based on the severity of the condition, with a focus on minimizing antibiotic use in uncomplicated cases, as evidenced by the most recent guidelines from the American College of Physicians 1.

Overview of Diverticulitis Treatment

The approach to treating diverticulitis depends on whether the condition is uncomplicated or complicated. Uncomplicated diverticulitis refers to localized inflammation without complications such as abscess, perforation, or obstruction, whereas complicated diverticulitis involves these more severe manifestations.

Uncomplicated Diverticulitis

For patients with uncomplicated diverticulitis, antibiotic therapy may not be necessary, especially in immunocompetent patients without systemic inflammatory response or sepsis, as suggested by recent studies 1. The use of antibiotics in these cases should be based on individual patient risk factors and clinical judgment. Supportive care, including bowel rest, hydration, and pain management with acetaminophen, can be sufficient for many patients.

Complicated Diverticulitis

In cases of complicated diverticulitis, antibiotic therapy is recommended, covering both Gram-negative and anaerobic bacteria. The choice of antibiotics and the route of administration (oral vs. intravenous) depend on the severity of the complication, the patient's ability to tolerate oral medications, and other clinical factors. Percutaneous drainage may be necessary for abscesses, and surgical intervention is considered for cases with perforation, peritonitis, obstruction, or recurrent episodes that do not respond to medical management.

Lifestyle Modifications

After recovery from an episode of diverticulitis, lifestyle modifications can help prevent recurrence. These include:

• A high-fiber diet (25-30g daily) to reduce pressure in the colon.
• Adequate hydration to soften stool and make it easier to pass.
• Regular exercise to improve bowel motility and overall health.
• Maintaining healthy bowel habits, such as responding to the urge to have a bowel movement and avoiding straining during defecation.

Evidence-Based Recommendations

The recommendations for the treatment of diverticulitis are based on the most recent and highest quality evidence available, including guidelines from professional societies like the American College of Physicians 1 and studies published in reputable medical journals 1. These sources emphasize the importance of tailoring treatment to the individual patient's condition, minimizing unnecessary antibiotic use, and promoting lifestyle changes to prevent recurrence.

From the Research

Treatment Options for Diverticulitis

• Antibiotics play a key role in the management of both uncomplicated and complicated diverticulitis 2
• Rifaximin has demonstrated to be effective in obtaining symptoms relief at 1 year in patients with uncomplicated diverticulitis and to improve symptoms and maintain periods of remission following acute colonic diverticulitis (AD) 2
• Conservative treatment with broad-spectrum antibiotics is successful in up to 70% of cases in patients with AD that develop an abscess 2

Antibiotic Treatment for Uncomplicated Diverticulitis

• The effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications in uncomplicated acute diverticulitis 3
• There may be little or no difference between antibiotics and no antibiotics for short-term complications in uncomplicated diverticulitis 3
• The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics in uncomplicated diverticulitis 3

Outpatient Treatment of Uncomplicated Diverticulitis

• Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective, and applicable to most patients with tolerance to oral intake and without severe comorbidity and having appropriate family support 4
• Oral antibiotics for 7 days (amoxicillin-clavulanic or ciprofloxacin plus metronidazole in patients with penicillin allergy) can be used for outpatient treatment of uncomplicated diverticulitis 4

Comparative Effectiveness of Antibiotics for Outpatient Diverticulitis

• There were no differences in 1-year admission risk, 1-year urgent surgery risk, 3-year elective surgery risk, or 1-year Clostridioides difficile infection risk between metronidazole-with-fluoroquinolone and amoxicillin-clavulanate for outpatient diverticulitis 5
• Treating diverticulitis in the outpatient setting with amoxicillin-clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 5

Treatment of Complicated Diverticulitis

• Ceftriaxone and metronidazole was found to be non-inferior to piperacillin/tazobactam for the combined primary outcome of 30-day readmission or all-cause mortality in patients with complicated diverticulitis 6
• No significant differences were found for 30-day antibiotic failure or 90-day Clostridioides difficile infection rate between ceftriaxone and metronidazole and piperacillin/tazobactam in patients with complicated diverticulitis 6