Diverticulitis Empiric Therapy
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Diverticulitis can be classified as mild, moderate, or severe. Treatment is based on clinical findings and the results of imaging studies. The mainstay of treatment includes antibiotic therapy, bowel rest, and analgesia. [1, 2, 3, 4, 5, 6, 7] The American Gastroenterological Association (AGA) suggests selective, rather than routine, use of antibiotics in patients with acute uncomplicated diverticulitis. [8]
In mild to moderate diverticulitis, localized symptoms are present without evidence of perforation, abscess, or significant comorbidity. Patients can be managed on an outpatient basis with close follow-up. Treatment also includes a clear liquid diet for 3-5 days and oral antibiotics. If there is no improvement in 2-3 days, the patient should be admitted for further workup.
Treatment recommendations:
Trimethoprim-sulfamethoxazole (160mg/800mg) 1 DS tablet PO BID plus metronidazole 500mg PO QID or
Ciprofloxacin 750mg PO BID plus metronidazole 500mg PO QID or
Levofloxacin 750 mg PO daily plus metronidazole 500mg PO QID or
Amoxicillin-clavulanate (875mg/125mg) PO BID or amoxicillin-clavulanate extended release (1,000mg/62.5mg) PO BID or
Moxifloxacin 400mg PO daily
Duration of therapy: 7-10d
Severe diverticulitis may include focal or generalized peritonitis, peridiverticular abscess, and systemic signs of sepsis. Inpatient treatment is recommended; surgical intervention may be required. Supportive care includes bowel rest; IV fluids; correction of electrolyte imbalance; and parenteral nutrition, if necessary.
Treatment recommendations:
Ciprofloxacin 400mg IV q12h plus metronidazole 500mg IV q6h or 1g IV q12h or
Levofloxacin 750mg IV q24h plus metronidazole 500mg IV q6h or 1g IV q12h or
Ceftriaxone 1-2g IV q24h plus metronidazole 500mg IV q6h or
Ceftolozane/tazobactam 1.5 g IV q8h plus metronidazole 500 mg IV q8h or
Ampicillin-sulbactam 3g IV q6h or
Ampicillin 2g IV q6h plus metronidazole 500mg IV q6h plus ciprofloxacin 400mg IV q12h or levofloxacin 750mg IV q24h
Ampicillin 2g IV q6h plus metronidazole 500mg IV q6h plus amikacin, gentamicin, or tobramicin
Piperacillin-tazobactam 3.375g IV q6h or 4.5g IV q8h or
Ticarcillin-clavulanate 3.1g IV q6h or
Ertapenem 1g IV q24h or
Imipenem/cilastatin 500mg IV q6h or
Meropenem 1g IV q8h or
Doripenem 500mg IV q8h or
Tigecycline 100mg IV first dose, then 50mg IV q12h
Duration of therapy: 7d
Overview
How is diverticulitis treated?
What are localized symptoms in mild to moderate diverticulitis?
What are the treatment recommendations for mild to moderate diverticulitis?
How is severe diverticulitis treated?
Faria GR, Almeida AB, Moreira H, Pinto-de-Sousa J, Correia-da-Silva P, Pimenta AP. Acute diverticulitis in younger patients: any rationale for a different approach?. World J Gastroenterol. 2011 Jan 14. 17(2):207-12. [Medline].
Masoomi H, Buchberg BS, Magno C, Mills SD, Stamos MJ. Trends in diverticulitis management in the United States from 2002 to 2007. Arch Surg. 2011 Apr. 146(4):400-6. [Medline].
Hemming J, Floch M. Features and management of colonic diverticular disease. Curr Gastroenterol Rep. 2010 Oct. 12(5):399-407. [Medline].
Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P, Soravia C. Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients. Dis Colon Rectum. 2002 Jul. 45(7):962-6. [Medline].
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15. 50(2):133-64. [Medline].
Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1. 87(9):612-20. [Medline].
Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar. 57(3):284-94. [Medline]. [Full Text].
[Guideline] Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec. 149(7):1944-9. [Medline]. [Full Text].
Samy A Azer, MD, PhD, MPH Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; Former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia
Samy A Azer, MD, PhD, MPH is a member of the following medical societies: American College of Gastroenterology, Association for Psychological Science, Gastroenterological Society of Australia, New York Academy of Sciences, Royal Society of Medicine, Sigma Xi
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.
Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic
Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio
Disclosure: Nothing to disclose.
Diverticulitis Empiric Therapy
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