What is the recommended treatment for diverticulitis with microperforation?

Treatment of Diverticulitis with Microperforation

For diverticulitis with microperforation, the recommended treatment is antibiotic therapy for 4 days combined with percutaneous drainage if an abscess >4 cm is present. 1

Classification and Initial Assessment

• Diverticulitis with microperforation is considered a form of complicated diverticulitis, characterized by localized perforation with pericolic air or small abscess formation 1, 2
• CT scan with IV contrast is the recommended imaging modality to confirm diagnosis and assess the extent of perforation and presence of abscess 1
• Key imaging findings include intestinal wall thickening, signs of inflammation in pericolonic fat, and evidence of perforation (extraluminal gas, intra-abdominal fluid) 1

Treatment Approach

Non-operative Management

• For hemodynamically stable patients with microperforation and small amounts of pericolic extraluminal gas without diffuse peritonitis, non-operative treatment with antibiotics is recommended 1, 2
• Patients with CT findings of distant free gas without diffuse intra-abdominal fluid may be treated non-operatively only if close follow-up can be performed, though this carries a significant failure rate (57-60%) 1
• Small diverticular abscesses (<4 cm) can be managed with antibiotic therapy alone for 7 days 1, 2

Percutaneous Drainage

• For larger diverticular abscesses (>4 cm), percutaneous drainage combined with antibiotic therapy for 4 days is recommended 1, 2
• If percutaneous drainage is not feasible in non-critically ill, immunocompetent patients, antibiotics alone could be considered 1
• In critically ill or immunocompromised patients where percutaneous drainage is not feasible, surgical intervention should be considered 1

Antibiotic Selection

• Empiric antibiotic regimen should be chosen based on the patient's clinical condition, presumed pathogens, and risk factors for antimicrobial resistance 1, 3
• For non-critically ill, immunocompetent patients with adequate source control, piperacillin/tazobactam 4g/0.5g q6h or eravacycline 1 mg/kg q12h is recommended 1, 3
• For patients with inadequate source control or at high risk of infection with ESBL-producing Enterobacterales, ertapenem 1g q24h or eravacycline 1 mg/kg q12h is recommended 1, 3
• In septic shock, use meropenem 1g q6h by extended infusion, doripenem 500mg q8h by extended infusion, imipenem/cilastatin 500mg q6h by extended infusion, or eravacycline 1 mg/kg q12h 1, 3
• For patients with documented beta-lactam allergy, eravacycline 1 mg/kg q12h or tigecycline 100 mg loading dose then 50 mg q12h is recommended 1

Duration of Antibiotic Therapy

• Antibiotic therapy should be administered for 4 days in immunocompetent and non-critically ill patients if source control is adequate 1, 3
• For immunocompromised or critically ill patients with adequate source control, antibiotic therapy for up to 7 days based on clinical condition and inflammatory markers is recommended 1
• The STOP IT trial demonstrated that outcomes after approximately 4 days of fixed-duration antibiotic therapy were similar to those after longer courses 1, 3

Surgical Management

• Surgery is indicated for patients with diffuse peritonitis, hemodynamic instability, or failure of non-operative management 1, 2
• Surgical options include:
  • Primary resection and anastomosis with or without a diverting stoma (for clinically stable patients without comorbidities) 1
  • Hartmann's procedure (for critically ill patients and/or those with multiple major comorbidities) 1
  • Laparoscopic peritoneal lavage and drainage (controversial, suitable only for patients with purulent peritonitis) 1

Monitoring and Follow-up

• Patients should be closely monitored for signs of treatment failure including persistent fever, increasing leukocytosis, or worsening clinical condition 1, 4
• Patients with ongoing signs of infection beyond 7 days of antibiotic treatment warrant additional diagnostic investigation 1
• Laboratory markers to monitor include white blood cell count, C-reactive protein, and procalcitonin 1, 4

Special Considerations

• Immunocompromised patients require more aggressive management and longer courses of antibiotics 1, 3
• Elderly patients may have atypical presentations and higher risk of complications, requiring careful monitoring 3, 4
• Patients with multiple comorbidities have higher risk of treatment failure and may require earlier surgical intervention 1, 5