Diverticulitis Empiric Therapy

Empiric Therapy Regimens

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, 8]} The American Gastroenterological Association (AGA) suggests selective, rather than routine, use of antibiotics in patients with acute uncomplicated diverticulitis.^[9]

Mild to moderate diverticulitis

In mild to moderate diverticulitis, localized symptoms are present without any 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 plusmetronidazole 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

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

• References

Author

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

Disclosure: Nothing to disclose.

Specialty Editors

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.

Chief Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

References

1. 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. [View Abstract]
2. 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. [View Abstract]
3. Hemming J, Floch M. Features and management of colonic diverticular disease. Curr Gastroenterol Rep. 2010 Oct. 12(5):399-407. [View Abstract]
4. 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. [View Abstract]
5. 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. [View Abstract]
6. Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1. 87(9):612-20. [View Abstract]
7. 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. [View Abstract]
8. Rezapour M, Stollman N. Antibiotics in uncomplicated acute diverticulitis: to give or not to give?. Inflamm Intest Dis. 2018 Dec. 3(2):75-9. [View Abstract]
9. [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. [View Abstract]