From the Guidelines
The first line treatment for uncomplicated diverticulitis should not include antibiotics in immunocompetent patients without signs of systemic inflammation, according to the most recent and highest quality evidence. This approach is supported by a strong recommendation based on high-quality evidence [ 1 ]. The use of antibiotics in 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 ].
Key Considerations
- The definition of uncomplicated acute diverticulitis is an anatomically confined inflammatory process, with CT findings including diverticula, thickening of the wall, and increased density of the pericolic fat [ 1 ].
- Patients with uncomplicated diverticulitis usually have an indolent course with a low incidence of subsequent complications [ 1 ].
- A multicenter randomized trial found that antibiotic treatment for acute uncomplicated diverticulitis neither accelerated recovery nor prevented complications or recurrence [ 1 ].
Treatment Approach
- For mild cases, outpatient management with dietary modifications and pain management is recommended [ 1 ].
- Patients should follow a clear liquid diet for 2-3 days, then gradually advance to a low-fiber diet as symptoms improve, before eventually returning to a high-fiber diet once the acute episode resolves [ 1 ].
- Pain management with acetaminophen or, if needed, non-steroidal anti-inflammatory drugs is appropriate [ 1 ].
- Patients should be advised to rest, maintain adequate hydration, and monitor for worsening symptoms such as increased pain, fever, or inability to tolerate oral intake [ 1 ].
Antibiotic Use
- Antibiotics should be reserved for the treatment of complicated diverticulitis or in patients with uncomplicated diverticulitis who have comorbidities, are frail, or have signs of systemic inflammation [ 1 ].
- When antibiotic treatment is necessary, the regimen usually includes broad-spectrum agents with gram-negative and anaerobic coverage, such as amoxicillin-clavulanate or the combination of metronidazole and a fluoroquinolone [ 1 ].
From the Research
First Line Treatment for Diverticulitis
- The first line treatment for diverticulitis depends on whether the condition is uncomplicated or complicated 2, 3, 4.
- For uncomplicated diverticulitis, outpatient treatment is recommended in afebrile, clinically stable patients 3, 5.
- Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence in uncomplicated diverticulitis, and should only be used selectively 3, 6.
- For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses 3, 4.
- Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration, and urgent surgery 3, 4.
Antibiotic Treatment
- The use of antibiotics in uncomplicated diverticulitis is uncertain, with low-certainty evidence suggesting little or no difference between antibiotics and no antibiotics in reducing short-term complications 6.
- The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics, but the evidence is uncertain due to wide confidence intervals 6.
- For complicated diverticulitis, broad-spectrum antibiotics are recommended, with the goal of covering both aerobic and anaerobic bacteria 2, 4.
Treatment Approach
- The treatment approach for diverticulitis should be individualized, taking into account the patient's overall health, severity of symptoms, and presence of complications 3, 5, 4.
- Patients with uncomplicated diverticulitis who are able to tolerate oral intake and have adequate family support may be treated as outpatients with oral antibiotics 5.
- Patients with complicated diverticulitis or those who are unable to tolerate oral intake should be hospitalized for intravenous antibiotics and bowel rest 3, 4.