Diverticulitis Treatment
Principles of Therapy
- Reserved for patients with complicated diverticulitis
- Small abscesses (<3 cm) are usually responsive to antibiotic treatment alone
- Antibiotics to be used should cover the usual pathogens in local infection:
- Anaerobes eg Bacteroides fragilis, Clostridium sp, Peptostreptococcus sp, Prevotella spp
- Aerobic organisms eg E coli, Klebsiella sp, Proteus sp, Enterobacteriaceae, enterococci, Streptococcus sp
- If an abscess is present, coverage for Pseudomonas aeruginosa should be given
- Local resistance patterns should be taken into consideration
- Other factors affecting the choice of antibiotics:
- History of antibiotic allergy
- Previous response to antibiotics
- Recent antibiotic use
Pharmacotherapy
Outpatient Antibiotic Therapy
- Oral broad-spectrum antibiotic therapy should be given for 7-10 days or up to 14 days depending on patient’s response
- Antibiotics that may be used include:
- Combination of Ciprofloxacin (or Levofloxacin) plus Metronidazole is frequently used
- Amoxicillin/clavulanic acid, Ampicillin/sulbactam or Co-trimoxazole
- Clindamycin or Moxifloxacin may be given to patients intolerant to Metronidazole
Inpatient Antibiotic Therapy
- Empiric broad-spectrum IV antibiotics should be administered to hospitalized patients (eg septic and immunocompromised) pending culture results with therapy adjusted once results are available
- IV antibiotic therapy is given for 3-5 days, then patient is transitioned to oral antibiotics to complete a 10- to 14-day course
Monotherapy that may be used includes the following:
- Coverage with a single antibiotic that has activity against potential pathogens has been shown to be as effective as combination therapy
- Beta-lactam/beta-lactamase combinations (eg aminopenicillins/beta-lactamase inhibitors, Piperacillin/tazobactam or Ticarcillin/clavulanic acid)
- Carbapenems are used for severe cases (eg Imipenem, Meropenem)
- Ertapenem may be used for mild-moderate disease
- Cephalosporins (2nd generation) with both aerobic/anaerobic Gram-negative coverage
- Eg Cefoxitin, Cefotetan
- These agents should be used with caution because B fragilis microorganisms have been increasingly found to be resistant to these agents
Combination therapy that may be used includes the following:
- Ampicillin plus Gentamicin plus Metronidazole
- Ciprofloxacin (or Levofloxacin) plus Metronidazole, with or without Ampicillin
- Piperacillin/tazobactam or Imipenem/cilastatin plus Metronidazole
- Metronidazole or Clindamycin plus (3rd generation cephalosporin or aminoglycoside)
- Severe penicillin/cephalosporin allergy: Aztreonam or Ciprofloxacin plus Metronidazole plus Vancomycin
Other Antibiotic
- Rifaximin plus fiber may provide relief in patients with uncomplicated symptomatic diverticular disease; however, it does not prevent recurrent diverticulitis
Pain Management
- May use Paracetamol for simple analgesia
- Meperidine is an appropriate choice if the patient requires narcotics for analgesia
- Avoid Morphine sulfate because it may cause colonic spasm
Hydration
Optimal fluid and electrolyte status should be maintained
Patients with Mild Disease (Outpatient)
- A liquid diet may be given with the diet advanced once symptoms improve
Patients with Moderate to Severe Disease (Inpatient)
- May be given clear liquid diet or be NPO (bowel rest) depending on symptom severity
- Administer intravenous (IV) fluids