What is the treatment for diverticulitis?

Treatment for Diverticulitis

Initial Management Strategy Based on Disease Severity

Treatment for diverticulitis should be tailored based on disease severity: uncomplicated diverticulitis is managed with observation and pain control (reserving antibiotics for high-risk patients), while complicated diverticulitis requires antibiotics, percutaneous drainage for large abscesses, or surgery depending on specific complications present. 1

Uncomplicated Diverticulitis

Outpatient management is appropriate for clinically stable, afebrile patients with uncomplicated diverticulitis, showing a low failure rate of only 4.3% and significant cost savings of €600-€1,900 per patient compared to hospitalization 2, 1.

Conservative Management (First-Line)

• Observation with pain management (typically acetaminophen) and clear liquid diet is the recommended initial approach 3
• Antibiotics should be selectively reserved for specific high-risk situations 3, 4

When to Use Antibiotics in Uncomplicated Diverticulitis

Antibiotics are indicated for patients with:

• Persistent fever or chills 3
• Increasing leukocytosis 3
• Age >80 years 3
• Pregnancy 3
• Immunocompromised status (chemotherapy, high-dose steroids, organ transplant) 3
• Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 3

Antibiotic Regimens for Uncomplicated Disease

• Oral therapy: Amoxicillin/clavulanic acid OR cefalexin plus metronidazole 3
• Intravenous therapy (if unable to tolerate oral): Cefuroxime or ceftriaxone plus metronidazole, OR ampicillin/sulbactam 3

Special Case: Pericolic Gas

• For CT findings of pericolic extraluminal gas (<5 cm from affected colon), attempt non-operative treatment with antibiotic therapy 2, 1
• Elevated CRP at presentation predicts treatment failure, requiring closer monitoring 2, 5
• Maintain high clinical suspicion for deterioration given sepsis-associated mortality 2

Complicated Diverticulitis

Small Abscesses (<4-5 cm)

• Initial trial of antibiotics alone is recommended 2, 1
• This approach has a pooled failure rate of 20% and mortality rate of only 0.6% 2
• Antibiotic duration: 7 days 5

Large Abscesses (≥4-5 cm)

• Percutaneous drainage combined with antibiotic therapy is the preferred approach 2, 1, 5
• Antibiotic duration: 4 days in immunocompetent patients if source control is adequate 5
• Up to 7 days in immunocompromised or critically ill patients 5
• If percutaneous drainage is not feasible and clinical conditions permit, antibiotics alone can be attempted with mandatory careful clinical monitoring 2

Antibiotic Regimens for Complicated Disease

• Intravenous therapy: Ceftriaxone plus metronidazole OR piperacillin-tazobactam 3
• For beta-lactam allergy: Eravacycline 1 mg/kg q12h OR Tigecycline 100 mg loading dose then 50 mg q12h 5

Important caveat: Augmentin (amoxicillin/clavulanate) is not specifically recommended for complicated diverticular abscesses due to limited coverage against potential pathogens in intra-abdominal infections; broader spectrum antibiotics are preferred 5.

Diffuse Peritonitis

• Prompt fluid resuscitation 1
• Immediate antibiotic administration 1
• Urgent surgical intervention with emergent laparotomy and colonic resection 1, 3
• Postoperative mortality: 0.5% for elective resection vs. 10.6% for emergent resection 3

Monitoring for Treatment Failure

Surgical intervention should be considered if:

• Patient shows worsening inflammatory signs 2, 5
• Abscess does not respond to medical therapy 2
• Ongoing signs of infection beyond 7 days warrant further diagnostic investigation 5

Postoperative Antibiotic Duration

4 days of postoperative antibiotic therapy is recommended if source control has been adequate, based on the STOP IT trial demonstrating similar outcomes to longer courses 1.

Elective Surgery Considerations

The decision for elective resection should be made case-by-case considering risk factors for recurrence, morbidity of surgery, ongoing symptoms, disease complexity, and patient comorbidities—the traditional recommendation for colectomy after 2 episodes is no longer accepted 1.