What is the management of acute diverticulitis?

From the Guidelines

Management of acute diverticulitis should be based on severity, with mild cases typically treated as outpatients without antibiotics, unless they have comorbidities, are frail, or present with refractory symptoms, vomiting, or elevated CRP levels, as suggested by the most recent guidelines 1. The approach to managing acute diverticulitis has evolved, with a focus on selective use of antibiotics. According to the American College of Physicians guideline published in 2022 1, outpatient management is suggested for most patients with acute uncomplicated left-sided colonic diverticulitis, with the option to forgo antibiotics in select cases. This approach is supported by the AGA clinical practice update on medical management of colonic diverticulitis, which advises antibiotic treatment in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 10^9 cells per liter 1. Key considerations in managing acute diverticulitis include:

• Severity of symptoms and presence of complications
• Patient comorbidities and immune status
• Presence of systemic inflammation, abscess, perforation, or obstruction
• Risk factors for progression to complicated diverticulitis, such as baseline ASA score III or IV, duration of symptoms longer than 5 days, presence of vomiting, CRP >140 mg/L, and baseline white blood cell count > 15 × 10^9 cells per liter
• Use of broad-spectrum antibiotics with gram-negative and anaerobic coverage when necessary
• Duration of treatment, which is usually 4-7 days but can be longer based on individual patient factors
• Importance of follow-up colonoscopy 6-8 weeks after resolution to exclude other pathologies, particularly in patients over 50 or those with concerning symptoms. In terms of specific antibiotic regimens, the AGA clinical practice update suggests that outpatient treatment of mild uncomplicated diverticulitis can include either a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate 1. For patients requiring hospitalization, IV antibiotics such as ceftriaxone plus metronidazole may be used 1. Overall, the management of acute diverticulitis requires a tailored approach, taking into account individual patient factors and the severity of symptoms, with a focus on selective use of antibiotics and prompt recognition and treatment of complications.

From the Research

Acute Diverticulitis Management

• The management of acute diverticulitis can be divided into uncomplicated and complicated cases 2
• Uncomplicated diverticulitis can be treated with outpatient management, including bowel rest and selective use of antibiotics 2
• Complicated diverticulitis requires non-operative management, including bowel rest and intravenous antibiotics, or surgical intervention in cases of peritonitis or failure of non-operative management 2

Antibiotic Treatment

• The use of antibiotics in uncomplicated diverticulitis is uncertain, with some studies suggesting no benefit in reducing the duration of the disease or preventing recurrence 3, 2
• In complicated diverticulitis, antibiotics such as ceftriaxone and metronidazole or piperacillin/tazobactam can be used, with ceftriaxone and metronidazole showing non-inferior outcomes to piperacillin/tazobactam 4
• The choice of antibiotic regimen may depend on the severity of the disease and the presence of comorbidities, with amoxicillin-clavulanate being a potential alternative to metronidazole-with-fluoroquinolone in outpatient settings 5

Treatment Outcomes

• The outcomes of antibiotic treatment for acute diverticulitis include the risk of complications, emergency surgery, recurrence, and mortality 3, 4, 5
• The quality of evidence for these outcomes is generally low, with more studies needed to determine the optimal treatment strategy 3
• Comparative effectiveness studies have shown no significant differences in outcomes between different antibiotic regimens, such as metronidazole-with-fluoroquinolone and amoxicillin-clavulanate 5