What is the treatment for diverticulitis?

From the Guidelines

Treatment for diverticulitis should be selective, with antibiotics used only in cases of complicated or severe disease, while mild uncomplicated cases may be managed without antibiotics, as supported by recent guidelines and studies 1. The management of diverticulitis depends on the severity of the condition, with mild cases often being managed on an outpatient basis.

• For mild uncomplicated diverticulitis, antibiotics may not be necessary, and treatment can focus on symptom management with rest, hydration, and over-the-counter pain relievers like acetaminophen, as well as a clear liquid diet for a short period before reintroducing solid foods 1.
• More severe cases or those with complications such as abscesses, perforation, or significant bleeding may require hospitalization for intravenous antibiotics, supportive care, and possibly surgical intervention.
• The use of antibiotics in diverticulitis, especially in uncomplicated cases, has been a topic of debate, with recent studies suggesting that antibiotics can be safely omitted in patients with a first episode of uncomplicated diverticulitis, as they do not accelerate recovery or prevent complications 1.
• For patients who do require antibiotics, the choice of antibiotic regimen should be based on the severity of the infection, the presumed pathogens, and local resistance patterns, with coverage for Gram-negative and anaerobic bacteria typically recommended 1.
• In cases of complicated diverticulitis, such as those with abscesses or perforation, antibiotic therapy should be tailored to cover the likely pathogens, and surgical consultation should be considered for source control and management of complications 1.
• After recovery from an episode of diverticulitis, lifestyle modifications including a high-fiber diet, adequate hydration, regular exercise, and weight management are recommended to reduce the risk of recurrence.

From the Research

Treatment Options for Diverticulitis

• The treatment for diverticulitis depends on the severity of the condition and whether it is classified as uncomplicated or complicated 2.
• For uncomplicated diverticulitis, outpatient treatment is recommended for afebrile, clinically stable patients 2, 3.
• Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence in patients with uncomplicated diverticulitis, and should only be used selectively 2, 4.

Antibiotic Treatment

• The use of antibiotics in uncomplicated diverticulitis is uncertain, with some studies suggesting that there may be little or no difference between antibiotics and no antibiotics in terms of short-term complications 4.
• A systematic review found that the evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications 4.
• For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses, while larger abscesses may require percutaneous drainage 2.
• A study comparing ceftriaxone and metronidazole to piperacillin/tazobactam found that ceftriaxone and metronidazole was non-inferior to piperacillin/tazobactam for the combined primary outcome of 30-day readmission or all-cause mortality 5.

Outpatient Treatment

• Outpatient treatment with oral antibiotics is safe and effective for patients with uncomplicated acute diverticulitis who are able to tolerate oral intake and have adequate family support 3.
• A study comparing metronidazole-with-fluoroquinolone to amoxicillin-clavulanate for outpatient diverticulitis found that there were 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 the two groups 6.

Surgical Intervention

• Surgical intervention is indicated for patients with peritonitis or sepsis, as well as for those who fail non-operative management 2.
• The type of surgical procedure used depends on the individual patient's condition and may include a Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy 2.