What is the treatment for diverticulitis (diverticulitis tx)?

Treatment of Diverticulitis

For uncomplicated diverticulitis, conservative management without antibiotics is recommended in immunocompetent patients without significant comorbidities, while antibiotics are necessary for complicated diverticulitis or in high-risk patients. 1

Classification and Diagnosis

Clinical Presentation

• Left lower quadrant abdominal pain
• Elevated temperature
• Localized tenderness in left lower quadrant
• Increased white blood cell count
• Elevated C-reactive protein and procalcitonin 1

Diagnostic Imaging

• CT scan with IV contrast is the preferred imaging modality
• Findings include:
  • Intestinal wall thickening
  • Pericolonic fat inflammation
  • Signs of perforation (if present): extraluminal gas, intra-abdominal fluid
  • Presence of abscess 1

Treatment Algorithm

1. Uncomplicated Diverticulitis

For immunocompetent patients without significant comorbidities:

• Conservative treatment without antibiotics 1
• Outpatient management if patient can take fluids orally and self-manage 1
• Re-evaluation within 7 days; earlier if clinical condition deteriorates 1

Antibiotics indicated if:

• Comorbidities present or patient is frail
• Refractory symptoms or vomiting
• CRP >140 mg/L or white blood cell count >15 × 10^9/L
• Fluid collection or longer segment of inflammation on CT 1
• Immunocompromised status 1

2. Complicated Diverticulitis

Small Diverticular Abscess (<4 cm)

• Antibiotic therapy alone for 7 days 1

Large Diverticular Abscess (>4 cm)

• Percutaneous drainage combined with antibiotic therapy for 4 days 1
• If drainage not feasible:
  • In stable, immunocompetent patients: antibiotics alone
  • In critically ill or immunocompromised patients: surgical intervention 1

Perforation with Peritonitis

• Surgical intervention:
  • For stable patients: Primary resection and anastomosis with/without diverting stoma 1
  • For critically ill patients: Hartmann's procedure 1

Antibiotic Regimens

For Outpatient Treatment (Uncomplicated)

• Oral fluoroquinolone (e.g., ciprofloxacin) plus metronidazole, OR
• Amoxicillin-clavulanate monotherapy 1
• Duration: 4-7 days 1

For Inpatient Treatment (Complicated)

Non-critically ill, immunocompetent patients:

• Piperacillin/tazobactam 4g/0.5g q6h, OR
• Ertapenem 1g q24h, OR
• Eravacycline 1mg/kg q12h 1
• Duration: 4 days if source control adequate 1

Critically ill or immunocompromised patients:

• Piperacillin/tazobactam 4g/0.5g q6h or 16g/2g by continuous infusion, OR
• Eravacycline 1mg/kg q12h 1
• Duration: up to 7 days based on clinical condition 1

For septic shock:

• Meropenem 1g q6h by extended/continuous infusion, OR
• Doripenem 500mg q8h by extended/continuous infusion, OR
• Imipenem/cilastatin 500mg q6h by extended infusion, OR
• Eravacycline 1mg/kg q12h 1

For beta-lactam allergy:

• Eravacycline 1mg/kg q12h, OR
• Tigecycline 100mg loading dose then 50mg q12h 1

Important Considerations

1. Outpatient vs. Inpatient Management:

   • Outpatient treatment is safe and effective for uncomplicated diverticulitis in patients without significant comorbidities 1, 2, 3
   • Inpatient care required for patients with significant comorbidities, inability to take oral fluids, or signs of sepsis 1

2. Duration of Antibiotic Therapy:

   • 4 days for uncomplicated cases with adequate source control 1, 4
   • Up to 7 days for immunocompromised or critically ill patients 1
   • Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 1

3. Surgical Management:

   • No longer recommended based solely on number of episodes 1
   • Decision should be individualized based on disease severity, complications, and patient factors 1

Common Pitfalls to Avoid

1. Overuse of antibiotics in uncomplicated diverticulitis in immunocompetent patients - recent evidence shows no benefit 1

2. Prolonged antibiotic courses beyond 4-7 days when source control is adequate - no additional benefit and increases risk of antibiotic resistance 1

3. Automatic surgical referral after specific number of episodes - current evidence does not support this practice 1

4. Failing to recognize high-risk patients who require antibiotics despite uncomplicated presentation (immunocompromised, elderly, comorbidities) 1

5. Inadequate follow-up - patients managed as outpatients should be re-evaluated within 7 days 1