Hospital Treatment for Diverticulitis
Most patients with uncomplicated acute diverticulitis do not require hospital admission and can be safely managed as outpatients with observation alone (no antibiotics) if they are immunocompetent, can tolerate oral intake, and have adequate home support. 1, 2
Patient Stratification: Who Needs Hospital Admission?
Admit to hospital if any of the following are present:
- Complicated diverticulitis (abscess, perforation, fistula, obstruction, or generalized peritonitis) 2, 3
- Inability to tolerate oral intake or maintain hydration 1, 2
- Significant comorbidities including cirrhosis, chronic kidney disease, heart failure, or poorly controlled diabetes 3, 2
- Immunocompromised status (chemotherapy, high-dose steroids, organ transplant recipients) 2, 3
- Severe systemic symptoms including persistent fever, chills, or signs of sepsis 2, 3
- Advanced age (>80 years) 2, 3
- High-risk clinical indicators: ASA score III or IV, symptoms >5 days, vomiting, pain score ≥8/10 2, 4
- High-risk laboratory values: CRP >140 mg/L or WBC >15 × 10^9/L 2, 3
- High-risk CT findings: large fluid collection, longer segment of inflammation, or pericolic extraluminal gas 1, 2
Inpatient Treatment Protocol
For Uncomplicated Diverticulitis Requiring Admission:
- IV fluid resuscitation for patients unable to maintain oral hydration 1, 5
- IV antibiotics with gram-negative and anaerobic coverage: 2, 3
- Ceftriaxone plus metronidazole, OR
- Cefuroxime plus metronidazole, OR
- Ampicillin/sulbactam, OR
- Piperacillin-tazobactam
- Transition to oral antibiotics as soon as tolerated to facilitate earlier discharge 2, 4
- Duration: 4-7 days for immunocompetent patients; 10-14 days for immunocompromised patients 2, 4
- Clear liquid diet during acute phase, advancing as symptoms improve 2, 4
For Complicated Diverticulitis:
Small abscesses (<4-5 cm):
Large abscesses (≥4-5 cm):
- Percutaneous CT-guided drainage combined with IV antibiotics 2, 4
- Antibiotic duration: 4 days for immunocompetent patients with adequate source control; up to 7 days for immunocompromised or critically ill patients 2
Generalized peritonitis:
- Emergent surgical consultation for laparotomy with colonic resection 3, 6
- Postoperative mortality: 10.6% for emergent surgery vs. 0.5% for elective surgery 3
Special Considerations for Pericolic Gas
Patients with CT findings of pericolic extraluminal gas should receive a trial of non-operative treatment with antibiotic therapy, maintaining high clinical suspicion for deterioration given the mortality risk associated with sepsis. 1 Only 8% of these patients fail non-operative management, with elevated CRP being the strongest predictor of failure. 1
Follow-Up and Monitoring
- Re-evaluate within 7 days of diagnosis; earlier if clinical condition deteriorates 1, 4
- Monitor for warning signs requiring immediate attention: fever >101°F, severe uncontrolled pain, persistent vomiting, inability to eat/drink, signs of dehydration 2
- Surgical consultation if clinical deterioration occurs despite appropriate medical management 2, 6
Common Pitfalls to Avoid
- Over-admitting low-risk patients: 94% of uncomplicated diverticulitis cases can be safely managed outpatient, with only 4.3% failure rate and significant cost savings (€600-1,900 per patient) 1
- Unnecessary antibiotics in immunocompetent patients with uncomplicated disease: Antibiotics do not accelerate recovery, prevent complications, or reduce recurrence rates in this population 2, 4, 6
- Delayed recognition of complicated disease: Maintain high index of suspicion in patients with risk factors, as approximately 5% progress to complicated diverticulitis 4
- Prolonged IV therapy when oral transition is appropriate: Early transition to oral antibiotics facilitates discharge without compromising outcomes 2, 4
- Failing to provide adequate follow-up: Establish reliable mechanisms for 7-day re-evaluation to catch early treatment failures 2