What is the treatment for diverticulitis?

Treatment of Diverticulitis

For immunocompetent patients with uncomplicated diverticulitis, antibiotics should not be routinely prescribed as they do not improve outcomes compared to symptomatic treatment alone. 1

Classification and Initial Approach

Diverticulitis is classified into two main categories:

1. Uncomplicated diverticulitis:

   • Localized inflammation without abscess or perforation
   • CT findings: diverticula, wall thickening, increased density of pericolic fat

2. Complicated diverticulitis:

   • Infection extending beyond the colon with abscess, perforation, or peritonitis

Treatment Algorithm

Uncomplicated Diverticulitis

For Immunocompetent Patients Without Systemic Inflammation:

• No antibiotics (strong recommendation based on high-quality evidence) 1
• Symptomatic treatment:
  • Clear liquid diet during acute phase
  • Advance diet as symptoms improve
  • Oral analgesics (acetaminophen)
  • Re-evaluation within 7 days 1

Consider Antibiotics For Uncomplicated Cases With:

• Comorbidities or frailty
• Refractory symptoms or vomiting
• CRP >140 mg/L or WBC >15 × 10^9/L
• Fluid collection or longer segment of inflammation on CT
• Immunocompromised status 1

Antibiotic Selection When Needed:

• Outpatient: Oral antibiotics
  • Amoxicillin-clavulanate OR
  • Ciprofloxacin plus metronidazole
  • Duration: 4-7 days 1
• Inpatient: IV antibiotics with gram-negative and anaerobic coverage
  • Switch to oral when clinically improved

Complicated Diverticulitis

• Mandatory antibiotic treatment with broad-spectrum coverage
• Surgical consultation for abscess, perforation, or obstruction
• Possible percutaneous drainage for abscesses

Outpatient vs. Inpatient Management

Outpatient Management Criteria:

• Uncomplicated diverticulitis
• Ability to tolerate oral intake
• No significant comorbidities
• Adequate pain control with oral analgesics
• Appropriate home support
• Temperature <100.4°F
• Pain score <4 on visual analog scale 1

Inpatient Management Criteria:

• Unable to tolerate oral intake
• Significant comorbidities
• Inadequate home support
• Complicated diverticulitis
• Immunocompromised status
• Severe pain or systemic signs of infection 1

Special Considerations

Immunocompromised Patients

• Higher risk for severe or complicated disease
• Lower threshold for:
  • Cross-sectional imaging
  • Antibiotic treatment (10-14 days)
  • Surgical consultation 1

Recurrence Prevention

• High-fiber diet after resolution (fruits, vegetables, whole grains)
• Regular physical activity
• Maintain normal BMI
• Smoking cessation
• Avoid non-aspirin NSAIDs 2

Common Pitfalls to Avoid

1. Overuse of antibiotics in uncomplicated cases - multiple studies show no benefit in immunocompetent patients 1, 3

2. Unnecessary hospitalization - outpatient treatment has been shown to be safe and effective in properly selected patients, with success rates over 92% 4, 5

3. Prolonged dietary restrictions - advance diet as symptoms improve rather than adhering to arbitrary timeframes

4. Failure to identify high-risk patients - those with comorbidities have higher treatment failure rates when antibiotics are withheld 3

5. Missing complicated diverticulitis - ensure proper imaging and assessment for patients with severe symptoms or concerning features

By following this evidence-based approach, most patients with uncomplicated diverticulitis can be safely managed without antibiotics, often in the outpatient setting, while reserving more aggressive interventions for those with complicated disease or high-risk features.