What is the recommended treatment for uncomplicated diverticulitis?

Treatment of Uncomplicated Diverticulitis

Conservative treatment without antibiotics is recommended for most patients with uncomplicated diverticulitis, particularly those who are immunocompetent and without systemic signs of inflammation. 1

Diagnostic Approach

• CT imaging is recommended when there is diagnostic uncertainty in suspected diverticulitis 1
• Clinical signs and symptoms typically include:
  • Abdominal pain in the left lower quadrant without vomiting
  • Elevated temperature
  • Localized tenderness in the left lower quadrant
  • Increased white blood cell count and C-reactive protein 1

Treatment Algorithm for Uncomplicated Diverticulitis

Step 1: Risk Stratification

Determine if the patient has any of these high-risk factors:

• Immunocompromised status
• Significant comorbidities or frailty
• Systemic inflammatory response
• Symptoms lasting >5 days
• Vomiting
• Pain score >7/10
• CRP >140 mg/L
• WBC >15 × 10^9 cells/L
• CT findings of pericolic extraluminal air, fluid collection, or longer inflamed colon segment 1

Step 2: Treatment Based on Risk Stratification

Low-Risk Patients (Immunocompetent, No Systemic Inflammation)

• Conservative treatment WITHOUT antibiotics 1
• Outpatient management 1
• Supportive care:
  • Bowel rest
  • Adequate hydration
  • Oral analgesics (acetaminophen) 1
• Re-evaluation within 7 days 1

High-Risk Patients

• Conservative treatment WITH antibiotics 1
• Antibiotic options:
  • Outpatient: Oral fluoroquinolone (e.g., ciprofloxacin 500mg twice daily) plus metronidazole (500mg three times daily) OR amoxicillin-clavulanate 1, 2, 3, 4
  • Inpatient (if needed): IV antibiotics with gram-negative and anaerobic coverage 1
• Duration: 5-7 days 1
• Consider hospitalization for patients unable to tolerate oral intake or with significant comorbidities 1

Special Considerations

Outpatient vs. Inpatient Management

• Outpatient management is appropriate for most uncomplicated cases 1
• Success rates of outpatient treatment exceed 90% 2, 3
• Outpatient treatment can reduce costs by approximately €1,600 per patient compared to inpatient management 3

When to Consider Hospitalization

• Inability to tolerate oral intake
• Severe pain
• Significant comorbidities
• Inadequate home support
• Signs of systemic inflammatory response 1

Follow-up

• Re-evaluation within 7 days for outpatients 1
• Earlier re-evaluation if clinical condition deteriorates 1
• Consider watchful waiting approach with ability to monitor patient status 1

Common Pitfalls to Avoid

1. Overuse of antibiotics in low-risk patients, which contributes to antibiotic resistance without improving outcomes 1
2. Unnecessary hospitalization of patients who can be safely managed as outpatients 1, 2, 3
3. Failure to recognize high-risk patients who would benefit from antibiotics 1
4. Inadequate follow-up for patients managed as outpatients 1

The evidence strongly supports a more selective approach to antibiotic use in uncomplicated diverticulitis, particularly in immunocompetent patients without systemic signs of inflammation. This approach is not only cost-effective but also helps combat antibiotic resistance while maintaining excellent clinical outcomes.