Management of Focal Diverticulitis Without Abscess
For this patient with uncomplicated diverticulitis and an elevated white blood cell count, you should discharge home with a course of oral antibiotics and close outpatient follow-up (option c). While recent guidelines support observation without antibiotics for most immunocompetent patients with uncomplicated diverticulitis, the presence of leukocytosis is a specific high-risk feature that warrants antibiotic therapy 1.
Risk Stratification and Decision Algorithm
This patient has uncomplicated diverticulitis (CT shows focal inflammation without abscess or fluid) but presents with a critical risk factor that changes management 1, 2:
- Elevated WBC count (leukocytosis) is specifically identified as an indication for antibiotic therapy, even in otherwise uncomplicated cases 1
- The American Gastroenterological Association recommends antibiotics for patients with WBC >15 × 10^9 cells per liter 1
- Additional risk factors warranting antibiotics include: CRP >140 mg/L, fluid collection or longer segment of inflammation on CT, symptoms >5 days, vomiting, or ASA score III or IV 1
Why Outpatient Management is Appropriate
This patient meets criteria for safe outpatient treatment despite needing antibiotics 1, 2:
- No fever - afebrile status supports outpatient management 2
- Normal blood pressure - hemodynamically stable 2
- No systemic signs of sepsis - no indication for IV therapy 1
- Able to tolerate oral intake - no vomiting mentioned 1
- Localized tenderness without peritoneal signs - no rebound or guarding indicates no perforation 3, 2
The World Journal of Emergency Surgery guidelines confirm that patients who can tolerate oral fluids, have no significant comorbidities, and have adequate home support are appropriate for outpatient management 1.
Recommended Antibiotic Regimen
First-line oral antibiotic options for 4-7 days 1:
- Ciprofloxacin 500 mg twice daily PLUS metronidazole 500 mg three times daily 1
- Alternative: Amoxicillin-clavulanate 875/125 mg twice daily 1
The duration should be 4-7 days for immunocompetent patients (10-14 days only if immunocompromised) 1.
Critical Follow-Up Requirements
Mandatory re-evaluation within 7 days, with instructions to return immediately if 1:
- Fever develops (>101°F)
- Pain worsens or becomes severe
- Persistent vomiting or inability to maintain hydration
- Development of peritoneal signs
Why Admission is NOT Necessary
Hospitalization is reserved for 1, 2:
- Complicated diverticulitis (abscess, perforation, peritonitis)
- Inability to tolerate oral intake
- Systemic inflammatory response or sepsis
- Immunocompromised status
- Significant comorbidities or frailty
- Failed outpatient management
This patient has none of these indications - she is clinically stable with localized disease 2.
Common Pitfall to Avoid
Do not withhold antibiotics simply because guidelines support observation in uncomplicated cases 1. The "no antibiotics" approach from landmark trials like DIABOLO specifically applies to patients without risk factors 1. Leukocytosis is explicitly listed as a criterion requiring antibiotic treatment, even when other features suggest uncomplicated disease 1. The guidelines emphasize selective rather than routine antibiotic use, meaning you must identify which patients need them 1.
Cost-Effectiveness Consideration
Outpatient management results in 35-83% cost savings per episode compared to hospitalization, without compromising outcomes when patients are appropriately selected 1.