What are the outpatient treatment options for diverticulitis (inflammation of the diverticula)?

From the Guidelines

Outpatient treatment for uncomplicated diverticulitis should be considered for select patients, with a focus on supportive care and without the use of antibiotics, unless the patient has comorbidities, is frail, or presents with refractory symptoms, vomiting, or signs of systemic inflammation. The management of acute uncomplicated diverticulitis has evolved, with recent evidence suggesting that antibiotics may not be necessary for all patients 1. A systematic review and meta-analysis found no difference in time to resolution or risk of readmission, progression to a complication, or need for surgery among patients treated with antibiotics compared to those not treated with antibiotics 1. The American College of Physicians recommends that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics, with the understanding that this approach is suitable for immunocompetent patients without systemic inflammatory response or immunosuppression, who are not medically frail, and can follow up as outpatients under medical supervision with social and family support 1. Key considerations for outpatient management include:

• Patient selection: Outpatient treatment is suitable for patients who can tolerate oral intake, have no significant comorbidities, and show no signs of complications such as perforation, abscess, or peritonitis.
• Supportive care: Patients should receive supportive care, including pain management with acetaminophen or non-steroidal anti-inflammatory drugs, and dietary modifications, such as a clear liquid diet for 2-3 days, followed by a gradual advancement to a low-fiber diet.
• Monitoring: Patients should be advised to seek immediate medical attention if they develop fever, severe abdominal pain, inability to tolerate oral intake, or signs of sepsis.
• Antibiotic use: Antibiotics should be reserved for patients with complicated diverticulitis, systemic inflammatory response, or immunosuppression, and for those who fail outpatient management without antibiotics. The use of antibiotics in outpatient treatment of uncomplicated diverticulitis should be guided by the presence of specific risk factors, such as comorbidities, frailty, or signs of systemic inflammation, as outlined in the AGA clinical practice update on medical management of colonic diverticulitis 1.

From the FDA Drug Label

The overall clinical success rates in the clinically evaluable patients are shown in Table 18 Table 18: Clinical Success Rates in Patients with Complicated Intra-Abdominal Infections StudyMoxifloxacin Hydrochloride n/N (%) Comparator n/N (%) 95% Confidence Intervala North America (overall) 146/183 (79.8%)153/196 (78.1%)(-7.4%, 9.3%) Abscess 40/57 (70.2%) 49/63 (77.8%)b NAc Non-abscess106/126 (84.1%)104/133 (78.2%)NA International (overall) 199/246 (80.9%)218/265 (82.3%)(-8.9%, 4. 2%) Abscess 73/93 (78.5%)86/99 (86.9%)NA Non-abscess 126/153 (82.4%)132/166 (79.5%)NA

Moxifloxacin can be used for the outpatient treatment of diverticulitis, which is a type of complicated intra-abdominal infection. The clinical success rates for moxifloxacin in the treatment of complicated intra-abdominal infections, including abscesses, were 70.2% to 84.1% in the clinically evaluable patients 2.

From the Research

Outpatient Treatment for Diverticulitis

• Outpatient treatment with oral antibiotics is a viable option for patients with uncomplicated diverticulitis, as shown in a study published in 2010 3.
• The study found that ambulatory treatment was safe, effective, and applicable to most patients with tolerance to oral intake and without severe comorbidity and having appropriate family support.
• A systematic review published in 2016 also supported the use of outpatient treatment with antibiotics, finding that treatment success rates ranged from 91.5 to 100% 4.
• The review noted that intolerance to oral intake and lack of family or social support are common exclusion criteria used for this approach, whereas severe comorbidities are not definitive exclusion criteria in all the studies.

Selection Criteria for Outpatient Treatment

• Patients with uncomplicated diverticulitis who are afebrile, clinically stable, and have no severe comorbidities may be suitable for outpatient treatment 5.
• The presence of comorbidities, inability to tolerate oral intake, and lack of family or social support are factors that may necessitate hospital admission.
• A study published in 1999 found that 65% of colon and rectal surgeons claimed to handle more than half of their patients with uncomplicated diverticulitis on an outpatient basis 6.

Antibiotic Treatment Options

• A study published in 2021 compared the effectiveness and harms of metronidazole-with-fluoroquinolone versus amoxicillin-clavulanate for outpatient diverticulitis, finding no differences in 1-year admission risk, 1-year urgent surgery risk, or 3-year elective surgery risk between the two groups 7.
• However, the study found that the 1-year risk of Clostridioides difficile infection was higher for metronidazole-with-fluoroquinolone than for amoxicillin-clavulanate.
• The choice of antibiotic treatment may depend on various factors, including patient tolerance, comorbidities, and potential side effects.