diverticulitis
DIVERTICULITIS
Diverticulitis is the acute inflammation of the diverticulum or saclike protrusion from the wall of the intestines caused by injury and bacterial proliferation. 
Abdominal pain is usually localized to the left lower quadrant, is abrupt, steady, severe and worsens over time.
Other signs and symptoms are fever, anorexia, nausea, vomiting, and altered bowel movements especially constipation but may also present with diarrhea or tenesmus.

Principles of Therapy

Decision to treat as outpatient vs inpatient will depend on clinical judgment of the physician, severity of the disease process, tolerance of oral intake, presence of comorbid illnesses, patient support system, & the probability that the condition will respond to outpatient therapy

Indications for Hospitalization of Patients with Uncomplicated Diverticulitis

  • Unable to tolerate oral intake
  • Patient needs narcotic analgesia for very severe pain
  • Significant peritoneal signs are present
  • A chronic underlying medical condition is present eg immunosuppression

Indications of Worsening Disease Requiring Hospitalization

  • Inability to tolerate oral fluids
  • Increase in fever
  • Worsening abdominal pain

Patients Receiving Outpatient Therapy

  • Reliability of patient & caregivers is an important consideration
  • Patient & caregiver should be advised that the patient should return to the emergency room or call physician if condition worsens
General Principles of Therapy
  • 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 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 Therapy

  • Empiric broad-spectrum intravenous (IV) antibiotics should be administered to hospitalized patients pending culture results with therapy adjusted once results are available
    • Intravenous (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
  • Metronidazole or Clindamycin plus (3rd generation cephalosporin or aminoglycoside)
  • Severe penicillin/cephalosporin allergy: Aztreonam or Ciprofloxacin plus Metronidazole

Other Antibiotic

  • Rifaximin plus fiber may provide relief in patients with uncomplicated symptomatic diverticular disease

Hydration

Optimal fluid & electrolyte status should be maintained

Patients with Mild Disease (Outpatient)

  • A liquid diet may be given

Patients with Moderate to Severe Disease (Inpatient)

  • May be given clear liquid diet or be non per orem (NPO) (bowel rest) depending on symptom severity
  • Administer intravenous (IV) fluids

Pain Management

  • Meperidine is an apt choice if the patient requires narcotics for analgesia
  • Avoid Morphine sulfate because it may cause colonic spasm
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