What is the recommended treatment for diverticulitis?

From the Guidelines

The recommended treatment for diverticulitis is to avoid antibiotics in immunocompetent patients with uncomplicated acute diverticulitis without signs of systemic inflammation, as supported by the most recent and highest quality study 1.

Key Considerations

• The definition of uncomplicated acute diverticulitis is crucial, and it is defined as localized diverticular inflammation without any abscess or perforation.
• The utility of antibiotics in acute uncomplicated diverticulitis has been a point of controversy, but recent evidence suggests that antimicrobial treatment is not superior to withholding antibiotic therapy in terms of clinical resolution, in patients with mild unperforated diverticulitis.
• A multicenter randomized trial published in 2012 by Chabok et al. involving ten surgical departments in Sweden and one in Iceland recruiting 623 patients with computed tomography-confirmed acute uncomplicated left-sided diverticulitis found that antibiotic treatment for acute uncomplicated diverticulitis neither accelerated recovery nor prevented complications or recurrence.

Treatment Approach

• For mild cases, outpatient management may be appropriate, with a focus on symptomatic treatment and monitoring.
• For moderate to severe cases, hospitalization may be necessary for intravenous antibiotics, bowel rest, and IV fluids.
• Complications like abscesses may require percutaneous drainage, while perforation, obstruction, or recurrent episodes might necessitate surgery.

Patient Selection for Outpatient Management

• Patients with uncomplicated acute diverticulitis symptoms without significant comorbidities, who are able to take fluids orally and manage themselves at home, can be treated as outpatients.
• Outpatient management is safe, with an overall failure rate of 4.3% (95% CI 2.6–6.3%), and can reduce healthcare costs without negatively influencing the quality of life of patients.

Antibiotic Therapy

• Antibiotic therapy should be reserved for patients with complicated diverticulitis or those with systemic manifestations of infection.
• The choice of antibiotic regimen should depend on the severity of infection, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns.

Postoperative Care

• After surgical source control in diffuse peritonitis due to diverticular perforation, a 4-day period of postoperative antibiotic therapy is suggested.

Long-term Management

• After recovery, patients should maintain a high-fiber diet, stay well-hydrated, exercise regularly, and avoid non-steroidal anti-inflammatory drugs to help prevent recurrence.

From the Research

Treatment Guidelines for Diverticulitis

The treatment for diverticulitis depends on the severity of the condition and whether it is classified as uncomplicated or complicated.

• For uncomplicated diverticulitis, outpatient treatment with oral antibiotics is recommended for patients who are afebrile, clinically stable, and have no severe comorbidity or lack of family support 2, 3.
• The use of antibiotics in uncomplicated diverticulitis has been questioned, with some studies suggesting that they may not be necessary 4.
• For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses, while larger abscesses should be drained percutaneously 5.
• Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration, and urgent surgery 5.

Antibiotic Treatment

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.

• A systematic review found that there may be little or no difference between antibiotics and no antibiotics in terms of short-term complications, but the quality of the evidence is low 4.
• Another study found that outpatient treatment with oral antibiotics is safe, effective, and applicable to most patients with uncomplicated acute diverticulitis 2.

Outpatient Treatment

Outpatient treatment has been shown to be viable in almost 95% of patients with uncomplicated acute diverticulitis, with treatment being effective in resolving inflammation and no complications in the majority of cases 3.

• A study found that outpatient treatment can save approximately 1,600 € per patient compared to inpatient treatment, with no significant difference in complications and relapse rates 3.
• The management of diverticulitis should be based on the classification of the condition as complicated or uncomplicated, with radiological evidence of inflammation using computed tomography (CT) scan 5.