What is the treatment for acute uncomplicated diverticulitis in the elderly?

From the Guidelines

Antibiotic therapy can be avoided in immunocompetent elderly patients with uncomplicated left colonic diverticulitis without sepsis-related organ failures. The most recent and highest quality study, published in 2022 in the World Journal of Emergency Surgery 1, suggests that antibiotic therapy should not be routinely used in elderly patients with uncomplicated diverticulitis. This is supported by the findings of the AVOD trial and the DIABOLO trial, which showed that antibiotic treatment in patients with uncomplicated acute left colonic diverticulitis (ALCD) neither accelerates recovery nor prevents complications or recurrences 1.

Key Considerations

• The WSES guidelines recommend avoiding antibiotic therapy in immunocompetent patients with uncomplicated diverticulitis without systemic manifestations of infection 1.
• A systematic review and meta-analysis including 2469 patients with acute uncomplicated diverticulitis showed that treatment without antibiotics might be feasible with outcomes comparable to antibiotic treatment 1.
• The AGA clinical practice update on medical management of colonic diverticulitis also recommends selective use of antibiotics in patients with uncomplicated diverticulitis, rather than routine use 1.
• Elderly patients with significant comorbidities, immunosuppression, inability to tolerate oral intake, or signs of systemic infection should be considered for hospitalization and antibiotic treatment 1.

Management Approach

• Outpatient management with pain control and dietary modifications may be sufficient for immunocompetent elderly patients with uncomplicated diverticulitis.
• Pain can be managed with acetaminophen, and a clear liquid diet can be recommended initially, followed by a gradual transition to a low-fiber diet and then a high-fiber diet.
• Medication adjustments for renal function, monitoring for dehydration, and careful assessment of comorbidities are crucial in elderly patients.

Antibiotic Use

• Antibiotics should be reserved for patients with complicated diverticulitis, systemic inflammation, abscess, perforation, or obstruction, or those with high-risk factors for progression to complicated diverticulitis 1.
• When antibiotic treatment is necessary, a broad-spectrum regimen with gram-negative and anaerobic coverage, such as amoxicillin-clavulanate or a combination of a fluoroquinolone and metronidazole, can be used 1.

From the Research

Treatment Options for Acute Uncomplicated Diverticulitis in the Elderly

• The treatment of acute uncomplicated diverticulitis in the elderly can be managed through various approaches, including outpatient treatment with oral antibiotics 2 or without antibiotics 3.
• Studies have shown that outpatient treatment with oral antibiotics can be safe and effective for most patients with uncomplicated acute diverticulitis, as long as they have tolerance to oral intake and do not have severe comorbidity or lack adequate family support 2, 4.
• The use of antibiotics in treating uncomplicated acute diverticulitis is still a topic of debate, with some studies suggesting that antibiotics may not be necessary for all patients 5, 3.
• A systematic review and meta-analysis found that treatment of acute uncomplicated diverticulitis without antibiotics is feasible, safe, and effective, with no significant differences in treatment failure, recurrence, complications, hospital readmissions, and need for surgery compared to antibiotic treatment 3.
• Another study compared the effectiveness and harms of metronidazole-with-fluoroquinolone versus amoxicillin-clavulanate for outpatient diverticulitis and found no differences in 1-year admission risk, 1-year urgent surgery risk, 3-year elective surgery risk, or 1-year Clostridioides difficile infection risk between groups 6.

Considerations for Elderly Patients

• Elderly patients with acute uncomplicated diverticulitis may require closer monitoring and more individualized treatment approaches due to potential comorbidities and age-related health issues.
• The choice of antibiotic treatment, if necessary, should be carefully considered in elderly patients, taking into account potential side effects and interactions with other medications 6.
• Outpatient treatment with oral antibiotics or without antibiotics may be a viable option for elderly patients with uncomplicated acute diverticulitis, as long as they have adequate support and monitoring 2, 4.