In a patient recently treated for sepsis secondary to sigmoid diverticulitis who now has recurrent nausea, vomiting, and tachycardia while on ciprofloxacin and metronidazole, what are the next management steps?

Recurrent Symptoms After Diverticulitis Treatment: Immediate Management

This patient requires urgent reassessment with CT imaging to evaluate for treatment failure, complications, or inadequate source control, followed by potential escalation to intravenous broad-spectrum antibiotics and surgical consultation if imaging reveals complicated disease. 1

Immediate Diagnostic Evaluation

The recurrence of nausea, vomiting, and tachycardia after recent sepsis treatment strongly suggests either treatment failure, inadequate source control, or development of complications. Early recognition of ongoing intra-abdominal sepsis is essential for effective treatment. 1

Critical Assessment Steps

• Obtain contrast-enhanced CT scan immediately to evaluate for abscess formation, perforation, fistula, obstruction, or inadequate drainage of existing collections 1
• Measure serum lactate as a marker of tissue hypoperfusion and sepsis severity 2
• Obtain blood cultures (at least two sets) before antibiotic escalation, but do not delay treatment beyond 45 minutes 2
• Assess for sepsis using clinical parameters: fever, tachycardia (already present), hypotension, altered mental status, oliguria, or lactic acidosis 1

Laboratory Monitoring

• Complete blood count to assess leukocytosis progression 1
• Basic metabolic panel for renal function and electrolyte abnormalities 1
• C-reactive protein to gauge inflammatory response 1
• Repeat lactate within 2-6 hours if initially elevated 2

Antibiotic Management Decisions

If Patient Shows Signs of Sepsis or Clinical Deterioration

Escalate immediately to intravenous broad-spectrum antibiotics covering ESBL-producing Enterobacteriaceae, given prior antibiotic exposure (ciprofloxacin/metronidazole) is a significant risk factor for resistant organisms. 1, 3

Recommended IV regimens:

• Piperacillin-tazobactam (first-line for complicated disease with prior antibiotic exposure) 2, 3
• Ceftriaxone plus metronidazole (alternative) 3
• Cefuroxime plus metronidazole (alternative) 3

Duration of Therapy

• Discontinue antibiotics at 4 days from adequate source control based on the STOP IT trial, which demonstrated non-inferiority of fixed 4-day therapy versus longer courses 1
• If signs of sepsis persist beyond 5-7 days despite adequate antibiotics, aggressive diagnostic investigation is warranted to search for undrained infection 1

Source Control Assessment

Delay in providing adequate source control is associated with adverse outcomes including death. 1 The timing and adequacy of source control are paramount in managing intra-abdominal infections. 1

CT Findings Dictate Management

If CT reveals abscess ≥4-5 cm:

• Percutaneous drainage combined with IV antibiotics is the preferred approach 1
• If percutaneous drainage is not feasible or unavailable, initial trial of IV antibiotics alone may be attempted in stable patients, but surgical consultation is mandatory 1

If CT shows pericolic gas only:

• Trial of non-operative treatment with IV antibiotics is reasonable 1
• However, increased CRP at presentation predicts treatment failure 1

If CT demonstrates free perforation or generalized peritonitis:

• Emergent laparotomy with colonic resection is required 3, 4
• Hartmann's procedure for critically ill patients with diffuse peritonitis 1
• Primary resection with anastomosis (with or without diverting stoma) for stable patients without major comorbidities 1

If CT shows Hinchey II disease (pericolic or pelvic abscess):

• Percutaneous drainage plus IV antibiotics 1
• Surgery if drainage fails or patient deteriorates 1

Resuscitation Protocol

Fluid Management

• Administer 30 mL/kg IV crystalloid bolus within first 3 hours for sepsis-induced hypoperfusion or lactate ≥4 mmol/L 2
• Use balanced crystalloids rather than 0.9% saline to avoid hyperchloremic acidosis 2
• Target clinical markers: decreased heart rate, increased blood pressure, improved mental status, urine output ≥0.5 mL/kg/hr 2

Vasopressor Support

• If hypotension persists despite adequate fluid resuscitation, initiate norepinephrine (first-line vasopressor) targeting mean arterial pressure ≥65-70 mmHg 1, 2
• Dopamine should be avoided due to increased risk of tachyarrhythmias 1

Critical Pitfalls to Avoid

• Do not delay imaging or surgical consultation while waiting for antibiotics to work - mortality increases 7.6% per hour of delay in adequate treatment 2
• Do not continue the same oral antibiotic regimen (ciprofloxacin/metronidazole) given treatment failure - escalation to IV therapy with broader coverage is required 1, 3
• Do not assume uncomplicated disease - recurrent symptoms after recent sepsis strongly suggest complicated diverticulitis requiring imaging 1
• Do not continue aggressive fluid resuscitation without hemodynamic response - this risks pulmonary edema and increased intra-abdominal pressure 2
• Do not delay source control procedures once identified - late or incomplete procedures have severely adverse outcomes 1

Monitoring Requirements

• Continuous vital signs: blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, urine output 2
• Tissue perfusion markers: capillary refill, skin mottling, extremity temperature, mental status 2
• Serial lactate measurements if initially elevated 2
• Daily assessment for signs of treatment failure: persistent fever, worsening abdominal pain, increasing leukocytosis 1

Surgical Consultation Timing

Immediate surgical consultation is required if:

• CT shows free perforation, generalized peritonitis, or large abscess not amenable to percutaneous drainage 1, 3
• Patient develops septic shock (hypotension requiring vasopressors despite adequate fluid resuscitation) 1, 2
• Clinical deterioration despite 24-48 hours of appropriate IV antibiotics and source control attempts 1