What is the recommended treatment for an adult patient with cocaine-induced diverticulitis?

Cocaine-Induced Diverticulitis Management

For an adult patient with cocaine-induced diverticulitis, immediate hospitalization with broad-spectrum IV antibiotics covering gram-negative and anaerobic bacteria is mandatory, along with urgent surgical consultation, as cocaine-associated enterocolitis carries a 50% surgical mortality when peritonitis develops and requires aggressive early intervention. 1

Critical Clinical Context

Cocaine-associated enterocolitis represents a distinct and high-risk variant of colonic inflammation that differs fundamentally from typical diverticulitis:

• Cocaine causes direct vascular injury through vasoconstriction and non-occlusive mesenteric ischemia, leading to transmural necrosis and necrotizing phlebitis in the bowel wall 1, 2
• The proximal colon is most commonly affected (14 of 18 patients in one series), though small bowel and distal colon involvement also occurs 1
• Symptoms typically present within 3 days of cocaine use, with 7 of 18 patients presenting within 24 hours and another 7 within 1-3 days 1
• Surgical mortality reaches 50% when peritonitis develops and laparotomy is required, compared to much lower mortality in standard diverticulitis 1

Immediate Management Algorithm

Step 1: Hospitalization and Risk Stratification

All patients with cocaine-associated enterocolitis require inpatient management regardless of initial presentation severity, as the standard outpatient criteria for uncomplicated diverticulitis do not apply to this ischemic variant 3, 1:

• Obtain CT scan with IV contrast immediately—10 of 11 patients in one series showed inflammatory or ischemic changes on imaging 1
• Assess for peritonitis: diffuse peritonitis (2/18 patients), single quadrant tenderness (11/18), or multi-quadrant tenderness (5/18) 1
• Urgent surgical consultation is mandatory given the 50% surgical mortality and rapid progression potential 1

Step 2: Antibiotic Selection

Initiate broad-spectrum IV antibiotics immediately with coverage for gram-negative and anaerobic bacteria, as cocaine-induced bowel ischemia creates a polymicrobial infection risk 4, 3:

• First-line IV regimen: Piperacillin-tazobactam 3.375-4.5g IV every 6-8 hours 3, 5
• Alternative regimen: Ceftriaxone 1-2g IV daily PLUS metronidazole 500mg IV every 8 hours 3, 5
• For septic shock or severe presentation: Consider meropenem, doripenem, or imipenem-cilastatin 5

The standard "selective antibiotic use" approach for uncomplicated diverticulitis does not apply to cocaine-associated cases, as the ischemic mechanism creates high complication risk 3, 1.

Step 3: Monitoring for Surgical Intervention

Maintain a low threshold for surgical intervention, as 4 of 18 patients (22%) required surgery, with 3 needing immediate laparotomy 1:

• Absolute indications for emergency surgery: Diffuse peritonitis, hemodynamic instability/shock, free intraperitoneal air, or clinical deterioration despite 24-48 hours of medical management 4, 1
• Surgical options: Primary resection with anastomosis in stable patients, or Hartmann's procedure in critically ill patients with diffuse peritonitis 4
• Monitor closely for progression: One patient in the literature developed peritonitis on Day 4 after initial nonoperative management 1

Step 4: Duration of Therapy

• Antibiotic duration: 7-14 days given the ischemic nature and high complication risk, longer than the 4-7 days used for standard uncomplicated diverticulitis 3, 5
• Transition to oral antibiotics only after clinical improvement (afebrile >24 hours, tolerating diet, improving abdominal exam): Ciprofloxacin 500mg PO twice daily PLUS metronidazole 500mg PO three times daily 3, 5

Critical Differences from Standard Diverticulitis

The cocaine-induced variant requires deviation from standard diverticulitis guidelines in several key areas:

• No role for observation without antibiotics: The high-quality evidence supporting selective antibiotic use in uncomplicated diverticulitis 3 does not apply to ischemic colitis from cocaine, which carries transmural necrosis risk 1, 2
• Outpatient management is contraindicated: Even patients without peritonitis require hospitalization given the unpredictable progression and 50% surgical mortality 1
• Longer antibiotic courses are justified: The 4-day post-source-control duration from the STOP IT trial 4 may be insufficient given the ischemic pathophysiology 1, 2

Additional Risk Factors to Address

• Cannabis co-use increases intestinal obstruction risk (OR 2.1 after adjustment), so screen for polysubstance use 6
• Opioid co-use worsens outcomes with higher rates of bleeding, sepsis, obstruction, and fistula formation, plus longer hospital stays 7
• Substance use disorder treatment referral is essential before discharge to prevent recurrence 1, 2

Common Pitfalls to Avoid

• Do not apply the "no antibiotics" approach from standard uncomplicated diverticulitis guidelines—cocaine-induced cases have fundamentally different pathophysiology with ischemic injury 3, 1
• Do not delay surgical consultation waiting for medical management to work—the 50% surgical mortality reflects delayed intervention in deteriorating patients 1
• Do not discharge patients early even with clinical improvement—one patient developed peritonitis on Day 4 after initial stabilization 1
• Do not miss the diagnosis by failing to obtain drug screening in young patients with abdominal pain and no traditional cardiac risk factors 2