Diverticulitis Treatment

• 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

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

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