Diverticulitis occurs when small, bulging pouches, known as diverticula, form in the wall of the large intestine and become inflamed or infected. These pouches, typically found in the lower part of the colon, are quite common, especially in individuals over 50 years of age. While the mere presence of these pouches, a condition called diverticulosis, usually causes no issues, their inflammation can lead to abdominal pain and other symptoms.
When Antibiotics Are Prescribed
Antibiotic prescription for diverticulitis depends on distinguishing between uncomplicated and complicated forms. Uncomplicated diverticulitis involves localized inflammation without complications like abscesses or perforations. Complicated diverticulitis includes an abscess, perforation, fistula, or bowel obstruction.
Symptoms prompting antibiotic consideration include significant pain, fever, nausea, and vomiting. Diagnostic findings such as an elevated white blood cell count or a high C-reactive protein (CRP) level, particularly above 140 mg/L, may also indicate the need for antibiotic treatment. A computed tomography (CT) scan is commonly used to confirm the diagnosis and identify any complications; findings like fluid collection or a longer segment of inflammation suggest antibiotics.
Medical guidelines have evolved, shifting away from routine antibiotic use for all cases of uncomplicated diverticulitis in stable patients. However, antibiotics are still advised for individuals with uncomplicated diverticulitis who have other health conditions, are frail, experience persistent symptoms, or are immunocompromised. Immunosuppressed patients, even with seemingly mild symptoms, face a higher risk of progressing to complicated diverticulitis or sepsis, underscoring the importance of antibiotic therapy in these instances.
Commonly Used Antibiotics
When antibiotics are deemed necessary for diverticulitis, treatment often involves a combination of medications to target the various bacteria found in the gut. For cases managed at home, common oral antibiotic regimens include ciprofloxacin combined with metronidazole, or amoxicillin-clavulanate as a single agent. Another oral option might be trimethoprim-sulfamethoxazole paired with metronidazole.
In more severe situations requiring hospitalization, intravenous (IV) antibiotics are administered. Common IV regimens include ceftriaxone plus metronidazole, or piperacillin-tazobactam. Ampicillin-sulbactam or carbapenems may also be used for broader coverage in inpatient settings. The duration of oral antibiotic treatment typically ranges from 7 to 10 days, while IV antibiotics are often given for 3 to 5 days, followed by a transition to oral antibiotics to complete a total course of 10 to 14 days.
Managing Uncomplicated Diverticulitis Without Antibiotics
For mild, uncomplicated diverticulitis, a conservative approach without antibiotics is increasingly favored, particularly for immunocompetent individuals. This strategy focuses on bowel rest and symptom management. A clear liquid diet is recommended for 2 to 3 days during a flare-up to allow the digestive system to recover.
As symptoms improve, the diet can gradually advance to low-fiber foods, eventually transitioning to a high-fiber diet once recovery is complete. Maintaining adequate hydration by drinking at least 8 to 10 glasses of water daily is also a component of this management plan. For pain relief, acetaminophen is generally recommended, while nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen should be avoided as they may irritate the digestive tract or increase the risk of bleeding. Close monitoring for any worsening symptoms, such as increased pain, persistent fever, inability to keep liquids down, or blood in the stool, is important, as these could indicate the need for medical re-evaluation.
Treatment for Complicated Diverticulitis
These scenarios necessitate immediate medical attention and hospitalization. Treatment often begins with intravenous antibiotics to combat infection.
For abscesses, particularly those larger than 4 centimeters, percutaneous drainage guided by imaging like CT scans or ultrasound is frequently performed by radiologists. This procedure helps to remove the collection of pus and can often stabilize the patient, potentially allowing for elective surgery later rather than an emergency procedure. In cases of severe complications like a significant perforation with widespread infection in the abdominal cavity, emergency surgery may be required. Surgical options can include removing the affected part of the colon, sometimes involving a temporary colostomy, or a laparoscopic washout for purulent peritonitis.