From the Guidelines
Antibiotic treatment for diverticulitis should be used selectively, rather than routinely, in immunocompetent patients with mild uncomplicated diverticulitis. This approach is supported by recent evidence from the American Gastroenterological Association (AGA) clinical practice update on medical management of colonic diverticulitis, which suggests that antibiotics do not provide a significant benefit in this patient population 1.
Key Considerations
- For patients with uncomplicated diverticulitis who have comorbidities, are frail, or present with refractory symptoms, vomiting, or elevated inflammatory markers (CRP >140 mg/L or baseline white blood cell count > 15 × 10^9 cells per liter), antibiotic treatment is advised 1.
- Patients with complicated diverticulitis or those with a fluid collection or longer segment of inflammation on CT scan should also receive antibiotic treatment.
- The choice of antibiotic regimen typically includes broad-spectrum agents with gram-negative and anaerobic coverage, such as a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate.
- The duration of antibiotic treatment is usually 4-7 days but can be longer based on individual patient factors, including general health status, immune status, severity of presentation, and CT findings.
Management Approach
- For mild cases of diverticulitis, home treatment with a clear liquid diet for a few days, followed by a gradual return to solid foods, is often recommended.
- Over-the-counter pain relievers like acetaminophen can help manage discomfort, but NSAIDs should be avoided due to the increased risk of bleeding.
- Severe cases may require hospitalization for intravenous antibiotics, bowel rest, and possibly surgical intervention if complications occur.
- After recovery, a high-fiber diet (25-30g daily) with adequate fluid intake and regular exercise can help prevent recurrence by promoting regular bowel movements and reducing pressure in the colon.
From the Research
Treatment Options for Diverticulitis
- 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 2
- Outpatient treatment with oral antibiotics is safe and effective for patients with uncomplicated acute diverticulitis who can tolerate oral intake and have adequate family support 3
- 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 4
- The use of antibiotics in uncomplicated diverticulitis is uncertain, with low-certainty evidence suggesting little or no difference between antibiotics and no antibiotics in terms of short-term complications 5
Complicated Diverticulitis Treatment
- Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses, while larger abscesses should be drained percutaneously 4
- Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration, and urgent surgery 4
- Ceftriaxone and metronidazole is non-inferior to piperacillin/tazobactam for the treatment of complicated diverticulitis, with no significant differences in 30-day readmission, all-cause mortality, or antibiotic failure 6
Follow-up and Prevention
- Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 4
- Mesalazine does not have any beneficial effect on preventing recurrent diverticulitis, while the efficacy of rifaximin and probiotics is still uncertain due to limited studies 2