Treatment of Diverticulitis
For uncomplicated diverticulitis, symptomatic treatment without antibiotics is recommended as first-line therapy, as antibiotics do not improve outcomes compared to symptomatic management alone. 1
Classification and Initial Management
Diverticulitis is classified into two main categories:
- Uncomplicated diverticulitis: Localized inflammation without abscess or perforation
- Complicated diverticulitis: Infection extending beyond the colon with abscess, perforation, or peritonitis
Uncomplicated Diverticulitis Management
For immunocompetent patients with uncomplicated diverticulitis:
- First-line treatment: Symptomatic management without antibiotics 1
- Clear liquid diet during acute phase
- Advance diet as symptoms improve
- Oral analgesics (acetaminophen)
- Re-evaluation within 7 days
This approach is supported by high-quality evidence showing no significant differences between antibiotic and non-antibiotic treatment regarding treatment failure, recurrence rates, complications, readmissions, or need for surgery 2.
Outpatient vs. Inpatient Management
Patients can be treated as outpatients if they meet all criteria 1:
- 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
Outpatient treatment has been shown to be safe and effective, with success rates over 92% 3.
Antibiotic Treatment
While not routinely recommended for uncomplicated cases, antibiotics are indicated in specific situations:
When to Use Antibiotics
- High-risk patients: Those who are immunocompromised or have significant comorbidities 1
- Complicated diverticulitis: Patients with abscess, perforation, or obstruction
- Patients with refractory symptoms, vomiting, elevated CRP or WBC
- Patients with fluid collection or longer segment of inflammation on CT
Antibiotic Regimens
Outpatient treatment (oral antibiotics for 4-7 days) 1, 3:
- Amoxicillin-clavulanate OR
- Ciprofloxacin plus metronidazole
Inpatient treatment:
- IV antibiotics with gram-negative and anaerobic coverage
- Switch to oral antibiotics when clinically improved
Prevention of Future Episodes
After resolution of acute diverticulitis, recommend 1:
- High-fiber diet (fruits, vegetables, whole grains)
- Regular physical activity
- Maintaining normal BMI
- Smoking cessation
- Avoiding non-aspirin NSAIDs
Important Considerations and Pitfalls
- Comorbidities matter: The presence of comorbidities is significantly associated with treatment failure in patients managed without antibiotics 2
- Surgical consultation: Required for patients with abscess, perforation, or obstruction 1
- Monitoring: High-risk patients require closer monitoring and possibly more aggressive treatment 1
- Emerging treatments: Some research suggests potential benefits of mesalazine (alone or with antibiotics) and probiotics in preventing recurrence, though these are not yet part of standard guidelines 4
The evidence strongly supports a more conservative approach to uncomplicated diverticulitis than was traditionally practiced, with symptomatic management being sufficient for most immunocompetent patients.