What are the treatment options and doses for diverticulitis?

From the Guidelines

Antibiotic treatment is advised in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 10^9 cells per liter, with recommended regimens including a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate. When considering treatment options for diverticulitis, it's essential to assess the severity and risk factors for complications. According to the AGA clinical practice update on medical management of colonic diverticulitis 1, patients with uncomplicated diverticulitis who are immunocompetent and have mild symptoms do not require antibiotic treatment. However, for those with high-risk features, such as comorbidities, frailty, refractory symptoms, vomiting, elevated CRP, or high white blood cell count, antibiotic treatment is necessary.

Some key points to consider in the treatment of diverticulitis include:

• The use of broad-spectrum antibiotics with gram-negative and anaerobic coverage, such as a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate 1.
• The duration of treatment, which is usually 4-7 days but can be longer based on individual patient factors, such as general health status, immune status, severity of presentation, CT findings, and patient expectations 1.
• Pain management with acetaminophen or NSAIDs, and dietary modifications, including a clear liquid diet initially, followed by a gradual advancement to low-fiber foods as symptoms improve.
• The importance of maintaining adequate hydration and rest during recovery, and recommending a high-fiber diet (25-30 g daily) after the acute episode resolves to prevent recurrence 1.

In terms of specific antibiotic regimens, the following options can be considered:

• Amoxicillin-clavulanate (875/125 mg twice daily) for 7-10 days
• A combination of metronidazole (500 mg three times daily) plus ciprofloxacin (500 mg twice daily) or trimethoprim-sulfamethoxazole (160/800 mg twice daily) for 7-10 days
• For severe cases requiring hospitalization, intravenous antibiotics such as ceftriaxone (1-2 g daily) plus metronidazole (500 mg every 8 hours), or piperacillin-tazobactam (3.375 g every 6 hours) can be administered until clinical improvement occurs 1.

From the Research

Treatment Options for Diverticulitis

• Outpatient treatment with oral antibiotics is a viable option for patients with uncomplicated diverticulitis, as shown in studies 2, 3.
• Antibiotics used in the treatment of uncomplicated diverticulitis include amoxicillin-clavulanic, ciprofloxacin, and metronidazole 2, 3.
• For patients with severe and complicated diverticulitis, antibiotics such as ampicillin, gentamicin, and piperacillin are used 4.
• Mesalazine and probiotics have also been shown to be effective in the treatment of diverticulitis, with mesalazine improving symptoms and preventing recurrence 4, 5.
• Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses, while larger abscesses may require percutaneous drainage 6.

Doses and Administration

• Oral antibiotics are typically administered for 7-10 days, with doses varying depending on the specific antibiotic used 2, 3.
• Amoxicillin-clavulanic is often given at a dose of 1g three times a day, while ciprofloxacin is given at a dose of 500mg twice a day 3.
• Metronidazole is often given at a dose of 500mg three times a day 2, 3.
• Mesalazine and probotics may be given in various doses and administration schedules, with mesalazine often given at a dose of 1-2g per day 5.

Specific Patient Populations

• Patients with uncomplicated diverticulitis who are afebrile and clinically stable may be treated as outpatients 6.
• Patients with complicated diverticulitis, such as those with abscesses or peritonitis, may require hospitalization and more aggressive treatment 6.
• Patients with certain risk factors, such as immunosuppression or diabetes, may require more individualized treatment plans 5.