What is the best treatment for diverticulitis?

From the Guidelines

The best treatment for diverticulitis is selective use of antibiotics, with outpatient management for uncomplicated cases and hospitalization for complicated cases, as recommended by the American College of Physicians 1.

Treatment Approach

The approach to treating diverticulitis depends on the severity of the condition. For mild cases, outpatient management with oral antibiotics (such as amoxicillin-clavulanate or ciprofloxacin plus metronidazole) for 7-10 days is recommended, along with a temporary liquid or low-fiber diet until symptoms improve. Rest and pain management with acetaminophen are also important.

Antibiotic Use

Antibiotic treatment is advised in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 10^9 cells per liter, as suggested by the AGA clinical practice update 1.

Hospitalization and Complications

For severe cases requiring hospitalization, treatment includes intravenous antibiotics (such as ceftriaxone plus metronidazole), bowel rest, and IV fluids. Complications like abscesses may require drainage procedures, while perforation, obstruction, or recurrent episodes might necessitate surgery.

Diet and Prevention

After recovery, a high-fiber diet (25-30 grams daily), regular exercise, adequate hydration, and avoiding non-steroidal anti-inflammatory drugs can help prevent recurrence, as recommended by the AGA clinical practice update 1.

Key Considerations

• The use of antibiotics should be selective, rather than routine, in patients with acute uncomplicated diverticulitis, as suggested by the AGA clinical practice update 1.
• Patients who are immunocompromised are at high risk for complications and should be treated with antibiotics, as recommended by the AGA clinical practice update 1.
• The presence of a fluid collection or longer segment of inflammation on baseline CT is associated with an increased risk of progression to complicated diverticulitis, as suggested by the AGA clinical practice update 1.
• A clear liquid diet is advised during the acute phase of uncomplicated diverticulitis, with the goal of patient comfort, as recommended by the AGA clinical practice update 1.
• The optimal antibiotic therapy for patients with diffuse peritonitis due to diverticular perforation should be chosen based on the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns, as suggested by the WSES guidelines 1.

From the Research

Treatment Options for Diverticulitis

• The treatment of diverticulitis depends on the severity of the disease, with uncomplicated cases often managed with outpatient treatment and complicated cases requiring hospitalization and more aggressive management 2.
• For patients with severe and complicated diverticulitis, antibiotics such as ampicillin, gentamicin, metronidazole, piperacillin, and tazobactam are commonly used, while ciprofloxacin, metronidazole, and rifaximin are used for uncomplicated cases 3.
• Mesalazine and probiotics are also being used as alternative therapies for the treatment of diverticulitis, with some studies showing significant improvement in symptoms and prevention of recurrence 3.

Outpatient Treatment

• Outpatient treatment with oral antibiotics has been shown to be safe and effective for patients with uncomplicated diverticulitis, with success rates of over 92% and a significant reduction in costs and medical resources 4, 5.
• A liquid diet and oral analgesics are also commonly used in outpatient treatment, with patients typically receiving a 10-day course of oral antibiotics such as metronidazole and ciprofloxacin 4, 5.

Antibiotic Selection

• The selection of antibiotics for the treatment of diverticulitis is often based on tradition, in vitro analyses, and pharmacokinetic profiling, with little evidence to support the use of specific antimicrobial regimens 6.
• However, antibiotics with activity against common gram-negative and anaerobic pathogens are generally recommended, with intravenous antibiotics used for hospitalized patients and oral therapy used for outpatient treatment or when the patient's condition improves 6.

Management of Complicated Diverticulitis

• Complicated diverticulitis is typically managed with non-operative treatment, including bowel rest and intravenous antibiotics, with surgical intervention reserved for cases with peritonitis, sepsis, or failure of non-operative management 2.
• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 2.