From the Guidelines
The management of complicated diverticulitis requires a multifaceted approach combining antibiotics, possible interventional procedures, and surgery in select cases, with the most recent guidelines suggesting antibiotic therapy alone for small diverticular abscesses (< 4–5 cm) and percutaneous drainage combined with antibiotic therapy for larger abscesses 1.
Initial Treatment
Initial treatment includes broad-spectrum antibiotics such as piperacillin-tazobactam (3.375g IV every 6 hours), or a combination of ciprofloxacin (400mg IV twice daily) and metronidazole (500mg IV every 8 hours), typically for 7-10 days, as recommended by recent clinical practice updates 1.
- Patients should be hospitalized for close monitoring, kept NPO (nothing by mouth), and receive IV fluids.
- The choice of antibiotic regimen should be based on the severity of the disease, patient's immune status, and local resistance patterns.
Interventional Procedures
Percutaneous drainage is indicated for abscesses larger than 4-5cm, performed under CT or ultrasound guidance, as suggested by the latest guidelines 1.
- Surgical intervention becomes necessary for patients with peritonitis, large undrainable abscesses, obstruction, or fistulas.
- The traditional approach involves a two-stage procedure with initial resection and colostomy (Hartmann's procedure) followed by later reversal, though single-stage resection with primary anastomosis may be appropriate for stable patients.
Surgical Considerations
Elective segmental resection should be personalized to consider severity of disease, patient preferences and values, as well as risks and benefits including quality of life, as recommended by recent clinical practice updates 1.
- Patients should understand that surgery reduces, but does not eliminate, diverticulitis risk and that chronic gastrointestinal symptoms do not always improve with surgery.
- Colectomy should not be advised to an immunocompetent patient with a history of recurrent uncomplicated diverticulitis to prevent complicated diverticulitis.
Follow-up Care
After resolution of the acute episode, colonoscopy is recommended 6-8 weeks later to exclude malignancy.
- Pain management should include opioid analgesics as needed.
- Patients with a history of complicated diverticulitis successfully managed without surgery are at increased risk of recurrence and complicated recurrence, and should be closely monitored.
From the FDA Drug Label
Complicated intra-abdominal infections included appendicitis, cholecystitis, diverticulitis, gastric/duodenal perforation, perforation of the intestine, and other causes of intra-abdominal abscesses and peritonitis. The management approach for complicated diverticulitis is to use ZERBAXA 1.5 g (ceftolozane 1 g and tazobactam 0.5 g) intravenously every 8 hours plus metronidazole (500 mg intravenously every 8 hours) for 4 to 14 days of therapy, as it has been shown to be non-inferior to meropenem in terms of clinical cure rates at the test-of-cure (TOC) visit in the microbiological intent-to-treat (MITT) population 2.
- Key points:
- ZERBAXA is used in combination with metronidazole.
- The treatment duration is 4 to 14 days.
- Clinical cure rates were lower in patients with baseline CrCl of 30 to 50 mL/min compared to those with CrCl greater than 50 mL/min.
- Monitor CrCl at least daily in patients with changing renal function and adjust the dosage of ZERBAXA accordingly.
From the Research
Management Approach for Complicated Diverticulitis
The management of complicated diverticulitis involves a combination of medical and surgical interventions. The following are key aspects of the management approach:
- Classification: Complicated diverticulitis is classified based on the presence of complications such as abscess, phlegmon, fistula, obstruction, bleeding, or perforation 3.
- Initial Management: Initial management includes intravenous fluid resuscitation and intravenous antibiotics 3.
- Imaging: Computed tomography (CT) is the most commonly performed imaging test to establish the diagnosis and extent of disease, and to exclude complications 3.
- Percutaneous Drainage: Patients with a localized abscess may be candidates for CT-guided percutaneous drainage 3.
- Surgical Intervention: Surgical intervention is indicated for patients with peritonitis, sepsis, or failure of non-operative management 3, 4.
- Antibiotic Therapy: The duration of antibiotic therapy for complicated diverticulitis is typically 10 days, and extending treatment beyond this period does not appear to improve outcomes 5.
- Colonoscopy: Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation 4.
Medical Management
Medical management of complicated diverticulitis involves the use of antibiotics, bowel rest, and supportive care. The following are key aspects of medical management:
- Antibiotic Selection: The choice of antibiotic therapy for complicated diverticulitis depends on the severity of disease and the presence of complications 6.
- Duration of Antibiotic Therapy: The duration of antibiotic therapy for complicated diverticulitis is typically 10 days 5.
- Bowel Rest: Bowel rest is recommended for patients with complicated diverticulitis to reduce symptoms and promote healing 4.
Surgical Management
Surgical management of complicated diverticulitis is indicated for patients with peritonitis, sepsis, or failure of non-operative management. The following are key aspects of surgical management: