From the Guidelines
For patients with acute uncomplicated left-sided colonic diverticulitis, treatment without antibiotics is recommended, as it does not increase the risk of complications or recurrence, and reduces the risk of antibiotic resistance and potential harms associated with antibiotic use. This approach is based on the most recent and highest quality evidence from the American College of Physicians guideline published in 2022 1. The guideline suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics, as low-certainty evidence showed that there may be no differences in diverticulitis-related complications, quality of life, need for surgery, or long-term recurrence between those receiving and those not receiving antibiotics.
Some key considerations for this approach include:
- The patient should be immunocompetent, with no systemic inflammatory response or immunosuppression, and not medically frail.
- The patient should be able to follow up as an outpatient under medical supervision with social and family support.
- Predictors of progression to complicated disease, such as symptoms lasting longer than 5 days, vomiting, systemic comorbidity, high C-reactive protein levels, or CT findings of pericolic extraluminal air, fluid collection, or a longer inflamed colon segment, should be taken into account.
- Initial management without antibiotics should be coupled with watchful waiting and the ability to continue monitoring patient status, based on individual clinical judgment.
Additionally, the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting also supports this approach, recommending not to prescribe antibiotic therapy in immunocompetent patients with uncomplicated acute diverticulitis without signs of systemic inflammation 1. This guideline suggests that antibiotics should be reserved for the treatment of complicated diverticulitis, and that symptomatic treatment without antibiotics can be safe and effective for uncomplicated cases.
In terms of specific treatment, patients with acute uncomplicated diverticulitis can be managed with supportive care, such as bowel rest and hydration, and can be treated as outpatients in most cases. A high-fiber diet and adequate hydration are recommended after recovery to prevent recurrence. Hospitalization may be necessary for patients with severe diverticulitis or complications, and surgical intervention may be required in cases of perforation, abscess, or obstruction.
From the Research
Treatment Options for Diverticulitis
- Uncomplicated diverticulitis can be treated without antibiotics, without bed rest, and without dietary restrictions, and a selected group of patients can be treated as outpatients 2
- For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 3, 4
- Complicated diverticulitis requires non-operative management, including bowel rest and intravenous antibiotics, for small abscesses, while larger abscesses should be drained percutaneously 3
- Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration, and urgent surgery 3
Antibiotic Treatment
- The effect of antibiotics on uncomplicated diverticulitis is uncertain, with low-certainty evidence suggesting little or no difference between antibiotics and no antibiotics in terms of short-term complications 4
- Ceftriaxone and metronidazole may be a suitable alternative to piperacillin/tazobactam for treating complicated diverticulitis, with non-inferior outcomes 5