What is the treatment for diverticulitis?

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 Diagnosis

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

Treatment Algorithm

Uncomplicated Diverticulitis

1. 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

2. Outpatient management criteria: 1, 2

   • 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

3. When to consider antibiotics:

   • Patients with comorbidities
   • Immunocompromised patients
   • Significant frailty
   • Refractory symptoms
   • Vomiting
   • Elevated CRP or WBC
   • Fluid collection or longer segment of inflammation on CT 1

Complicated Diverticulitis

1. Mandatory antibiotic treatment:

   • Inpatient: IV antibiotics with gram-negative and anaerobic coverage
   • Switch to oral when clinically improved 1

2. Surgical consultation for:

   • Abscess
   • Perforation
   • Obstruction 1

Antibiotic Options (When Indicated)

• Outpatient regimens (7-10 days):

  • Amoxicillin-clavulanate OR
  • Ciprofloxacin plus metronidazole 1, 2

• Inpatient regimens:

  • Ampicillin, gentamicin, metronidazole
  • Piperacillin-tazobactam 3

Prevention of Recurrence

• High-fiber diet (fruits, vegetables, whole grains)
• Regular physical activity
• Maintain normal BMI
• Smoking cessation
• Avoid non-aspirin NSAIDs 1

Evidence Strength and Considerations

The recommendation against routine antibiotics for uncomplicated diverticulitis is supported by high-quality evidence. A meta-analysis of 9 studies including 2,565 patients found no significant differences between non-antibiotic and antibiotic treatment groups regarding treatment failure (OR = 1.5, p = 0.06), recurrence (OR = 0.81, p = 0.2), complications (OR = 0.56, p = 0.25), readmission rates (OR = 0.97, p = 0.91), need for surgery (OR = 0.59, p = 0.28), and mortality (OR = 0.64, p = 0.47) 4.

Outpatient management has been shown to be safe and effective in multiple studies, with success rates over 92% 5, 6. This approach can result in significant cost savings of approximately €1,600 per patient compared to inpatient treatment 6.

Common Pitfalls to Avoid

• Overuse of antibiotics in uncomplicated cases - current evidence shows symptomatic treatment is equally effective
• Unnecessary hospitalization - most uncomplicated cases can be managed as outpatients
• Failure to identify high-risk patients who require closer monitoring or antibiotics
• Inadequate follow-up - patients should be re-evaluated within 7 days
• Neglecting prevention strategies after resolution of acute episode