From the Guidelines
For uncomplicated diverticulitis, antibiotics are not necessary in immunocompetent patients without signs of systemic inflammation, and treatment should focus on symptomatic relief. The use of antibiotics in uncomplicated diverticulitis has been a point of controversy, with recent evidence suggesting that antibiotic treatment is not superior to withholding antibiotic therapy in terms of clinical resolution in patients with mild unperforated diverticulitis 1.
When antibiotic treatment is necessary, the regimen usually includes broad-spectrum agents with gram-negative and anaerobic coverage. In the outpatient setting, treatment of mild uncomplicated diverticulitis most commonly includes either a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate 1. The recommended oral antibiotic regimen is typically amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily for 7-10 days. An alternative option is the combination of metronidazole 500 mg three times daily plus either ciprofloxacin 500 mg twice daily or trimethoprim-sulfamethoxazole (Bactrim DS) one tablet twice daily, also for 7-10 days.
Some key points to consider in the management of diverticulitis include:
- The risk of progression to complicated diverticulitis is 5%, and risk factors for progression include baseline ASA score III or IV, duration of symptoms longer than 5 days prior to presentation, presence of vomiting, CRP >140 mg/L, and baseline white blood cell count > 15 × 10^9 cells per liter 1.
- Patients who are immunocompromised are at high risk for complications and should be treated with antibiotics.
- Antibiotics are mandatory for the treatment of diverticulitis complicated by evidence of systemic inflammation, abscess, perforation, or obstruction.
- Patients should be educated on the importance of a high-quality diet, normal body mass index, physical activity, not smoking, and avoiding nonsteroidal anti-inflammatory drug use except aspirin prescribed for secondary prevention of cardiovascular disease to reduce the risk of recurrence 1.
The decision to use antibiotics in uncomplicated diverticulitis should be made on a case-by-case basis, taking into account the patient's individual risk factors and severity of symptoms. It is essential to ensure adequate hydration and monitor for worsening symptoms, which may indicate treatment failure requiring hospitalization for intravenous antibiotics.
From the Research
Recommended Oral Antibiotics for Acute Diverticulitis
- The recommended oral antibiotics for uncomplicated acute diverticulitis include amoxicillin-clavulanic acid or ciprofloxacin plus metronidazole in patients with penicillin allergy 2, 3.
- Another study suggests that ciprofloxacin, metronidazole, and rifaximin can be used in the treatment of uncomplicated diverticular disease 4.
- A prospective non-randomized study compared the efficacy, safety, and costs of hospital treatment with intravenous antibiotics and outpatient treatment with oral antibiotics, and found that outpatient treatment with oral antibiotics (metronidazole and ciprofloxacin) is viable in almost 95% of patients with uncomplicated acute diverticulitis 5.
Treatment Protocols
- Ambulatory treatment protocols for uncomplicated acute diverticulitis typically consist of oral antibiotics for 7-10 days, a clear liquid diet for the first 2 days, and pain control with oral acetaminophen 2, 3, 5.
- Patients with vomiting, severe comorbidities, or without an appropriate family environment are usually excluded from ambulatory treatment protocols 2, 3.
Safety and Efficacy
- Studies have shown that ambulatory treatment of uncomplicated acute diverticulitis is safe, effective, and applicable to most patients with tolerance to oral intake and without severe comorbidity 2, 3, 5.
- Outpatient treatment has demonstrated a safety and efficiency similar to inpatient treatment, producing an important reduction in expenses and medical resources 5.