What is the recommended treatment for inpatient management of diverticulitis?

Inpatient Management of Diverticulitis

For patients requiring inpatient management of diverticulitis, treatment should include broad-spectrum antibiotics with gram-negative and anaerobic coverage, bowel rest, and intravenous fluids, with consideration for percutaneous drainage for abscesses >4-5 cm. 1

Patient Selection for Inpatient Management

• Inpatient management is indicated for patients with complicated diverticulitis (abscess, perforation, fistula, obstruction, or bleeding) 1, 2
• Patients with uncomplicated diverticulitis should be hospitalized if they have:
  • Systemic inflammatory response or sepsis 1
  • Immunocompromised status (corticosteroid use, chemotherapy, organ transplant) 1
  • Inability to tolerate oral intake 1, 2
  • Severe pain or inadequate pain control 2
  • Significant comorbidities or advanced age (>80 years) 1, 2
  • High risk factors for progression: symptoms >5 days, vomiting, CRP >140 mg/L, WBC >15 × 10^9/L, or fluid collection/longer segment of inflammation on CT 1

Antibiotic Therapy

• Intravenous antibiotics with gram-negative and anaerobic coverage are indicated for all inpatients with diverticulitis 1
• Recommended regimens include:
  • Ceftriaxone plus metronidazole 2, 3
  • Piperacillin-tazobactam 2, 3
  • Ampicillin-sulbactam 3
• Duration of therapy:
  • 4-7 days for immunocompetent patients 1, 2
  • 10-14 days for immunocompromised patients 1
• Transition to oral antibiotics (fluoroquinolone plus metronidazole or amoxicillin-clavulanate) when the patient improves and can tolerate oral intake 1, 2, 4

Supportive Care

• Bowel rest with clear liquid diet initially, advancing as symptoms improve 2, 5
• Intravenous fluid resuscitation 1, 5
• Pain management, typically with acetaminophen 3
• Avoid NSAIDs and opioids when possible, as they may increase risk of complications 3

Management of Complicated Diverticulitis

• For small abscesses (<4-5 cm), antibiotic therapy alone for 7 days 2, 6
• For large abscesses (>4-5 cm), percutaneous CT-guided drainage combined with antibiotic therapy 1, 2
• Surgical consultation for patients with:
  • Peritonitis 1, 6
  • Large abscesses not amenable to percutaneous drainage 1, 2
  • Clinical deterioration despite medical therapy 2, 6
  • Immunocompromised status 1

Monitoring and Follow-up

• Daily assessment of clinical status, vital signs, and laboratory parameters 1, 2
• Consider repeat imaging if clinical improvement is not observed within 2-3 days 1, 2
• Transition to outpatient management when:
  • Patient is afebrile for 24 hours 1, 7
  • Pain is adequately controlled 2, 7
  • Patient can tolerate oral intake 1, 7
  • Laboratory values are improving 2, 7
• Follow-up colonoscopy 4-6 weeks after resolution of symptoms for patients with complicated diverticulitis or for age-appropriate screening 5, 6

Special Considerations

• Immunocompromised patients require more aggressive management with longer duration of antibiotics (10-14 days) and lower threshold for surgical consultation 1
• Elderly patients (>80 years) have higher risk of complications and may require longer hospitalization 2, 3
• Patients with recurrent episodes may benefit from surgical consultation for possible elective colectomy 1, 5

Common Pitfalls to Avoid

• Delaying antibiotics in patients with complicated diverticulitis or high-risk factors 1, 2
• Failing to recognize clinical deterioration requiring surgical intervention 1, 2
• Inadequate fluid resuscitation in patients with sepsis 1, 3
• Premature discharge before adequate clinical improvement 1, 7
• Unnecessary prolonged courses of antibiotics in patients who have clinically improved 2, 4