From the Guidelines
The next step for this 70-year-old male with worsening diverticular abscess despite 72 hours of Vancomycin and Zosyn should be percutaneous drainage of the abscess. The enlarging abscess size (from 5 cm to 8 cm) and persistent fever indicate treatment failure with antibiotics alone, as suggested by the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1. According to the guidelines, patients with large abscesses should be treated with percutaneous drainage combined with antibiotic treatment, as the size of 4–5 cm may be a reasonable limit between antibiotic treatment alone versus percutaneous drainage combined with antibiotic treatment in the management of diverticular abscesses 1. Key considerations for the management of this patient include:
- Percutaneous drainage should be performed by interventional radiology, with placement of a drainage catheter to evacuate the purulent material.
- Cultures of the drained material should be obtained to guide targeted antibiotic therapy.
- The patient should continue broad-spectrum antibiotics (Vancomycin and Zosyn) until culture results return, at which point therapy can be narrowed.
- Following resolution of the acute infection, an interval elective sigmoid colectomy should be considered, typically 6-8 weeks later, to prevent recurrence. This approach is recommended because diverticular abscesses larger than 4-5 cm generally require drainage in addition to antibiotics, and the enlarging size despite appropriate antimicrobial therapy indicates the need for source control through drainage 1.
From the Research
Management of Recurrent Diverticulitis with Perforation Abscess
The patient in question is a 70-year-old male with recurrent diverticulitis and a perforation abscess of 5 cm, initially treated with vancomycin and zosyn, but showing no improvement after 72 hours with persistent fever, and new imaging revealing an increased abscess size to 8 cm.
- The initial approach of using broad-spectrum antibiotics such as vancomycin and zosyn is in line with recommendations for managing complicated diverticulitis, as indicated by 2 and 3.
- Given the patient's lack of response to initial antibiotic treatment and the increase in abscess size, the next step should consider more invasive management strategies. According to 3, larger abscesses (of 3-5 cm or larger) may require percutaneous drainage.
- The presence of persistent fever and an increase in abscess size despite antibiotic treatment suggests a failure of conservative management, which may necessitate a more aggressive approach, including possible surgical intervention, as suggested by 4 and 3.
- The decision for surgical intervention should be based on the patient's overall clinical condition, the severity of the disease, and the failure of non-operative management. Elective surgery may be considered to prevent recurrent disease, especially in cases of complicated diverticulitis, as discussed in 5 and 6.
- It's also important to consider the role of colonoscopy in the management plan, as recommended by 3 and 5, for evaluating the colon after an episode of diverticulitis, especially if there are suspicious features on CT scan or if the patient meets national bowel cancer screening criteria.