From the Guidelines
For post-operative perforated diverticulitis, a 4-day period of postoperative antibiotic therapy is suggested after surgical source control, with the choice of empiric antibiotic regimen based on the patient's clinical condition, presumed pathogens, and risk factors for antimicrobial resistance patterns. The selection of antibiotics should consider coverage for Gram-positive and Gram-negative bacteria, as well as anaerobes, given the intestinal microbiota involved in large bowel acute diverticulitis 1.
Key considerations in choosing an antibiotic regimen include:
- The severity of infection
- The pathogens presumed to be involved
- The risk factors indicative of major resistance patterns, such as prior exposure to antibiotics and comorbidities requiring concurrent antibiotic therapy 1
- Local epidemiological data and resistance profiles
Given the increasing prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae in community-acquired infections, anti-ESBL-producer coverage should be warranted 1. A typical regimen might include piperacillin-tazobactam or a combination of ceftriaxone plus metronidazole, with alternatives for patients with penicillin allergy, such as ciprofloxacin plus metronidazole or meropenem for severe cases.
It is crucial to narrow the antibiotic spectrum based on culture results if available and to switch to oral antibiotics once the patient can tolerate oral intake, with options like amoxicillin-clavulanate or ciprofloxacin plus metronidazole 1. The goal of treatment is clinical improvement, including resolution of fever, normalization of white blood cell count, and return of bowel function, alongside adequate hydration, pain management, and monitoring for signs of recurrent infection.
From the Research
Post-Operative Management of Perforated Diverticulitis
- The management of perforated diverticulitis is a challenging aspect of general surgery, with various treatment options available depending on the severity of the condition 2.
- In cases of generalized peritonitis, surgery is indicated, and the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock 3.
- For patients with perforated diverticulitis without generalized peritonitis, conservative management with antibiotics is a viable option, with a success rate of 94.0% and 71.4% for patients with pericolic and distant free air, respectively 4.
Antibiotic Therapy
- Broad-spectrum antibiotics are recommended for the treatment of perforated diverticulitis, with the goal of controlling infection and preventing further complications 5, 4.
- The use of antibiotics in conjunction with other treatment modalities, such as percutaneous drainage or surgical intervention, may be necessary in some cases 3, 6.
Surgical Intervention
- Surgical options for perforated diverticulitis include Hartmann's procedure, primary resection and anastomosis, and laparoscopic lavage, each with its own advantages and disadvantages 2, 3, 6.
- The choice of surgical procedure depends on various factors, including the severity of the condition, the patient's overall health, and the presence of any complications 3, 6.
- Laparoscopic lavage is associated with an increased risk of major complications compared to primary resection for Hinchey III diverticulitis, while primary resection and anastomosis may be the optimal management strategy for perforated diverticulitis 6.