From the Guidelines
For diverticulitis with microperforation in an inpatient setting, the recommended antibiotic regimen is a combination of intravenous (IV) therapy with either piperacillin-tazobactam 3.375g every 6 hours, or a combination of ceftriaxone 1-2g daily plus metronidazole 500mg every 8 hours, as these regimens provide broad-spectrum coverage against gram-negative rods, gram-positive cocci, and anaerobes commonly found in intestinal flora 1.
Key Considerations
- The microperforation indicates a complicated infection requiring coverage for potential peritoneal contamination, which is why broad-spectrum antibiotics are necessary.
- The choice of antibiotic regimen should be based on the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns 1.
- The duration of antibiotic therapy should be 4-7 days, followed by oral antibiotics to complete a 10-14 day total course 1.
Oral Step-Down Therapy
- For oral step-down therapy, amoxicillin-clavulanate 875/125mg twice daily or a combination of ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily is appropriate 1.
- Patients should be monitored for clinical improvement, including resolution of fever, reduction in abdominal pain, normalization of white blood cell count, and ability to tolerate oral intake before transitioning to oral antibiotics and considering discharge.
Recent Guidelines
- Recent guidelines suggest that antibiotic treatment can be used selectively, rather than routinely, in immunocompetent patients with mild acute uncomplicated diverticulitis 1.
- However, in patients with complicated diverticulitis, such as those with microperforation, antibiotic treatment is strongly advised 1.
From the Research
Recommended Antibiotics for Diverticulitis with Micro Perforation
The recommended antibiotics for diverticulitis with micro perforation in an inpatient setting are:
- Ceftriaxone and metronidazole, as they have been found to be non-inferior to piperacillin/tazobactam for the treatment of complicated diverticulitis 2
- Piperacillin/tazobactam, as it is a commonly used antibiotic for the treatment of complicated diverticulitis 2, 3
Considerations for Antibiotic Choice
When choosing an antibiotic for diverticulitis with micro perforation, the following considerations should be taken into account:
- The risk of Clostridioides difficile infection, which may be higher with the use of fluoroquinolones 4
- The risk of enterococcal infection, which may be higher with the use of ceftriaxone 5
- The presence of antibiotic-resistant organisms, which may require the use of broader-spectrum antibiotics 3
Antibiotic Regimens to Avoid
The following antibiotic regimens may not be recommended for diverticulitis with micro perforation: