From the Guidelines
The treatment for acute uncomplicated diverticulitis typically involves outpatient management without antibiotics, with a focus on pain control, dietary modifications, and close follow-up. According to the most recent and highest quality study, patients with acute uncomplicated left-sided colonic diverticulitis can be managed without antibiotics, as the evidence suggests 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 1.
Key Considerations
- Patients should be started on a regimen of pain control, such as acetaminophen or non-steroidal anti-inflammatory drugs, and advised to rest and maintain adequate hydration.
- Dietary modifications, such as a clear liquid diet for 2-3 days, followed by a gradual advancement to a low-fiber diet, can help manage symptoms and allow the inflamed colon to heal.
- Close follow-up is essential, with instructions to return if symptoms worsen, fever develops, or pain becomes uncontrollable.
- Hospitalization becomes necessary if the patient cannot tolerate oral intake, has severe pain, shows signs of complications, or has significant comorbidities.
Evidence-Based Recommendations
- The American College of Physicians suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting, without the use of antibiotics, unless there are signs of systemic inflammatory response or immunosuppression 1.
- The use of antibiotics without evidence of important benefit to the patient may incur potential harms, such as increased costs and contribution to antibiotic resistance 1.
- Predictors of progression to complicated disease among patients with uncomplicated acute diverticulitis include symptoms lasting longer than 5 days, vomiting, systemic comorbidity, high C-reactive protein levels, and CT findings of pericolic extraluminal air or fluid collection 1.
Clinical Implications
- Clinicians should err on the side of imaging in patients with predictors of progression to complicated diverticulitis, and consider the use of abdominal ultrasonography or magnetic resonance imaging when CT cannot be obtained 1.
- The implementation of this recommendation does not require a CT-confirmed diagnosis, but clinicians should be aware of the potential benefits and harms of CT imaging in the diagnosis and management of acute diverticulitis 1.
From the Research
Treatment Overview
The treatment for acute uncomplicated diverticulitis can vary, but the following points summarize the common approaches:
- Antibiotics are often used, but the choice of antibiotic can differ 2.
- Outpatient treatment with oral antibiotics is considered safe and effective for most patients 3.
- The use of antibiotics versus no antibiotics has been studied, with some research suggesting that avoiding antibiotics may be a safe and efficacious way to manage acute uncomplicated diverticulitis 4.
Antibiotic Choices
The choice of antibiotics can vary, with common options including:
- Second-generation cephalosporins 2.
- Ampicillin/sulbactam 2.
- Ciprofloxacin [(2,3)].
- Metronidazole [(2,3,5)].
- Amoxicillin-clavulanate [(3,5)].
Treatment Duration and Follow-up
- The duration of antibiotic treatment is typically 7-10 days [(2,3)].
- Follow-up examinations may include sigmoidoscopy, barium enema, or colonoscopy 2.
Comparison of Treatment Approaches
- Studies have compared the effectiveness and harms of different antibiotic regimens, including metronidazole-with-fluoroquinolone versus amoxicillin-clavulanate 5.
- Research suggests that treating diverticulitis in the outpatient setting with amoxicillin-clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 5.