What is the treatment for diverticulitis?

From the Guidelines

Treatment of diverticulitis should be individualized based on the severity of the condition, with antibiotics used selectively in immunocompetent patients with mild uncomplicated diverticulitis, as recent evidence suggests no benefit in this population 1.

Key Considerations

• For mild cases, outpatient management with oral antibiotics such as ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily for 7-10 days may be considered, along with a clear liquid diet and pain management with acetaminophen or non-steroidal anti-inflammatory drugs.
• Patients with comorbidities, frailty, refractory symptoms, vomiting, CRP >140 mg/L, or baseline white blood cell count > 15 × 10^9 cells per liter should receive antibiotic treatment 1.
• Hospitalization may be required for moderate to severe cases, with intravenous antibiotics, bowel rest, and IV fluids.
• Complications like abscess formation may require percutaneous drainage, while perforation, obstruction, or recurrent episodes might necessitate surgical intervention, typically sigmoid colectomy.

Antibiotic Selection

• The choice of antibiotic regimen should depend on the severity of infection, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns 1.
• Consideration of local epidemiological data and resistance profiles is essential for antibiotic selection.
• Anti-ESBL-producer coverage should be warranted in patients with prior exposure to antibiotics and comorbidities requiring concurrent antibiotic therapy.

Prevention of Recurrence

• After recovery, a high-fiber diet (25-30g daily) and adequate hydration are recommended to prevent recurrence by reducing pressure in the colon.
• Regular exercise and maintaining healthy bowel habits also help prevent future episodes by promoting normal bowel function and reducing constipation risk.

From the Research

Treatment Options for Diverticulitis

• Uncomplicated diverticulitis can be treated without antibiotics, without bed rest, and without dietary restrictions 2
• Outpatient treatment is feasible and safe for uncomplicated and mild complicated diverticulitis 3
• Broad-spectrum antibiotics covering both aerobic and anaerobic bacteria are usually used to treat acute uncomplicated diverticulitis 4
• The use of antibiotics for uncomplicated diverticulitis is uncertain, with low-certainty evidence suggesting little or no difference between antibiotics and no antibiotics for short-term complications 5

Antibiotic Treatment

• Antibiotic therapy is usually administered for 7 to 10 days, but the duration can be longer if complications occur 4
• There is no evidence to support the recommendation of any prophylactic diet or medical treatment for reducing the risk of first or recurrent diverticulitis in patients with diverticulosis 4
• The general recommendation is to use antibiotics with activity against common gram-negative and anaerobic pathogens, but there is little evidence to base selection of specific antimicrobial regimens 6
• Intravenous antibiotics are recommended for initial treatment of severe episodes of diverticulitis, with oral therapy used for outpatient treatment or when the patient's condition improves 6

Patient Subgroups

• Patients on immunosuppression or non-steroidal anti-inflammatory drugs may have a higher risk of complicated diverticulitis 2
• Young patients do not seem to have a higher risk of complicated diverticulitis, but the risk of recurrent diverticulitis in young patients is conflicting 2
• Patients with isolated pericolic extraluminal air can be treated conservatively 2