From the Guidelines
Antibiotics should be used selectively in patients with acute uncomplicated diverticulitis, and are recommended for those with comorbidities, refractory symptoms, vomiting, CRP >140 mg/L, or baseline white blood cell count > 15 × 10^9 cells per liter, as well as for patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan. When antibiotic treatment is necessary, the regimen usually includes broad-spectrum agents with gram-negative and anaerobic coverage, such as a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate 1. The duration of treatment is usually 4–7 days but can be longer, depending on the patient's general health status, immune status, severity of presentation, CT findings, and patient expectations 1. For severe or complicated cases requiring hospitalization, intravenous antibiotics such as ceftriaxone plus metronidazole, piperacillin-tazobactam, or ertapenem may be necessary until symptoms improve, followed by oral antibiotics to complete a 7-14 day course 2. Some key points to consider when treating diverticulitis with antibiotics include:
- Selective use of antibiotics in immunocompetent patients with mild uncomplicated diverticulitis 3
- Consideration of local epidemiological data and resistance profiles when selecting antibiotics 2
- Coverage for Gram-positive and Gram-negative bacteria, as well as anaerobes, is essential for treating complicated acute diverticulitis 2
- Anti-ESBL-producer coverage should be warranted in patients with risk factors for ESBL-producing pathogens, such as prior exposure to antibiotics and comorbidities requiring concurrent antibiotic therapy 2. While taking antibiotics, patients should maintain a clear liquid diet initially, gradually advancing to low-fiber foods as symptoms improve, and ensure adequate hydration. Pain management with acetaminophen is recommended, avoiding NSAIDs which may worsen symptoms. Patients should contact their doctor if symptoms worsen, fever persists, or they experience severe abdominal pain, as these may indicate complications requiring more aggressive treatment.
From the Research
Diverticulitis Treatment with Antibiotics
- The use of antibiotics in treating diverticulitis is a topic of ongoing debate, with some studies suggesting that antibiotics may not be necessary for uncomplicated cases 4.
- A systematic review of randomized controlled trials found that the effect of antibiotics on complications, emergency surgery, recurrence, and long-term complications in uncomplicated acute diverticulitis is uncertain, with low-certainty evidence 4.
- However, other studies have shown that antibiotics can be effective in treating diverticulitis, particularly in cases where there is an abscess or other complications 5, 6.
- Outpatient treatment with oral antibiotics has been shown to be safe and effective for patients with uncomplicated diverticulitis who are able to tolerate oral intake and have adequate family support 7.
- The choice of antibiotic regimen is not well established, but guidelines recommend using antibiotics with activity against common gram-negative and anaerobic pathogens 6.
- The optimal duration of antimicrobial therapy is also not well established, and more research is needed to determine the best course of treatment 6.
Complicated vs. Uncomplicated Diverticulitis
- Complicated diverticulitis, which includes cases with abscesses, perforation, or peritonitis, typically requires more aggressive treatment, including intravenous antibiotics and possibly surgery 5, 8.
- Uncomplicated diverticulitis, on the other hand, may be treated with outpatient management, including bowel rest and selective use of antibiotics 8.
- The classification of diverticulitis as complicated or uncomplicated is based on CT scan findings, severity of symptoms, and patient history, and is used to direct management 8.
Guidelines and Recommendations
- Guidelines recommend that antibiotics be used selectively in patients with uncomplicated diverticulitis, and only in cases where there is a clear benefit 8.
- For complicated diverticulitis, guidelines recommend non-operative management, including bowel rest and intravenous antibiotics, for small abscesses, and surgical intervention for larger abscesses or cases with peritonitis or sepsis 8.
- Colonoscopy is recommended for all patients with complicated diverticulitis, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 8.