From the Guidelines
Antibiotics are not recommended for uncomplicated diverticulitis in immunocompetent patients.
Rationale
- The evidence from recent studies, including a multicenter randomized trial by Chabok et al. 1, suggests that antibiotic treatment does not accelerate recovery, prevent complications, or prevent recurrence in patients with uncomplicated diverticulitis.
- The 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting also recommends against prescribing antibiotic therapy in immunocompetent patients with uncomplicated diverticulitis without signs of systemic inflammation 1.
- The AGA clinical practice update on medical management of colonic diverticulitis advises antibiotic treatment only in patients with uncomplicated diverticulitis who have comorbidities, are frail, or have refractory symptoms, vomiting, or elevated inflammatory markers 1.
Key Points
- Uncomplicated diverticulitis is defined as localized diverticular inflammation without any abscess or perforation.
- The current consensus is that uncomplicated acute diverticulitis may be a self-limiting condition in which local host defenses can manage the inflammation without antibiotics in immunocompetent patients.
- Antibiotics should be reserved for the treatment of complicated diverticulitis or in patients with high-risk features, such as immunocompromised status, systemic inflammation, or evidence of sepsis.
- When antibiotic treatment is necessary, broad-spectrum agents with gram-negative and anaerobic coverage are usually recommended, with a duration of treatment typically ranging from 4 to 7 days.
From the Research
Antibiotic Use in Uncomplicated Diverticulitis
- The use of antibiotics in uncomplicated diverticulitis has been a topic of debate, with recent studies suggesting that they may not be necessary 2, 3, 4, 5, 6.
- A systematic review and meta-analysis published in 2019 found that patients with uncomplicated diverticulitis can be monitored off antibiotics, with no significant difference in outcomes between those who received antibiotics and those who did not 2.
- Another study published in 2018 found that current evidence does not support the administration of antibiotics to improve outcomes in carefully selected healthy patients with acute uncomplicated left-sided diverticulitis 3.
- A retrospective population-based cohort study published in 2014 found that a no-antibiotic policy for acute uncomplicated diverticulitis is safe and applicable in clinical practice, with low complication and recurrence rates 4.
- More recent studies, including a review of current trends in the treatment of acute uncomplicated diverticulitis published in 2024, have found similar outcomes in cases of acute uncomplicated diverticulitis treated with or without antibiotics, leading to societal guidelines recommending against the routine use of antibiotics in acute uncomplicated diverticulitis 5.
- A systematic review and meta-analysis published in 2023 found no statistically significant difference in outcomes between patients with acute uncomplicated diverticulitis who were put on observational therapy compared to the antibiotics regime, suggesting that observational therapy is an equally safe and effective therapy as compared to antibiotics therapy 6.
Key Findings
- No significant difference in outcomes between patients with uncomplicated diverticulitis who receive antibiotics and those who do not 2, 3, 4, 5, 6.
- Low complication and recurrence rates with a no-antibiotic policy for acute uncomplicated diverticulitis 4.
- Observational therapy is an equally safe and effective therapy as compared to antibiotics therapy for acute uncomplicated diverticulitis 6.
- Societal guidelines recommend against the routine use of antibiotics in acute uncomplicated diverticulitis 5.