*'''1. Community-acquired infection in adults''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345 }} </ref>
:*'''1.1. Mild-to-moderate severity (perforated or abscessed appendicitis and other infections of mild-to-moderate severity):'''
::*'''1.1.1. Single agent:'''
:::*Preferred regimen (1): [[Cefoxitin]] 2 g IV q6h
:::*Preferred regimen (2): [[Ertapenem]] 1 g IV q24h
:::*Preferred regimen (3): [[Moxifloxacin]] 400 mg IV q24h
:::*Preferred regimen (5): [[Ticarcillin]]-[[clavulanic acid]] 3.1 g IV q6h; FDA labeling indicates 200 mg/kg/day in divided doses every 6 h for moderate infection
::*'''1.1.2. Combination:'''
:::*Preferred regimen (1): [[Cefazolin]] 1–2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (2): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (3): [[Ceftriaxone]] 1–2 g IV q12–24 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (4): [[Cefotaxime]] 1–2 g IV q6–8 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (5): [[Ciprofloxacin]] 400 mg IV q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:::*Preferred regimen (6): [[Levofloxacin]] 750 mg IV q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h {{or}} 1500 mg q24h
:*'''1.2. High risk or severity (severe physiologic disturbance, advanced age, or immunocompromised state):'''
::*'''1.2.1. Single agent:'''
:::*Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h
:::*Preferred regimen (2): [[Meropenem]] 1 g IV q8h
:::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h
:::*Preferred regimen (4): [[Piperacillin-tazobactam]] 3.375 g IV q6h
::*'''1.2.2. Combination:'''
:::*Preferred regimen (1): [[Cefepime]] 2 g q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
:::*Preferred regimen (2): [[Ceftazidime]] 2 g q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
:::*Preferred regimen (3): [[Ciprofloxacin]] 400 mg q12h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
:::*Preferred regimen (4): [[Levofloxacin]] 750 mg q24h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
:::*Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
*'''2. Health Care–Associated Complicated Intra-abdominal Infection''' <ref name="pmid20034345">{{cite journal| author=Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al.| title=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. | journal=Clin Infect Dis | year= 2010 | volume= 50 | issue= 2 | pages= 133-64 | pmid=20034345 | doi=10.1086/649554 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20034345 }} </ref>
:*'''2.1. Less than 20% Resistant Pseudomonas aeruginosa, Extended-spectrum B-lactamase-producing Enterobacteriaceae, Acinetobacter, or other multidrug resistant gram-negative bacilli:'''
::*Preferred regimen (1): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (2): Imipenem-cilastatin 500 mg IV 6 h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (3): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg IV every 8–12 h or 1500 mg q24h
::*Preferred regimen (4): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg q8–12 h or 1500 mg q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (6): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Cefepime]] 2 g IV q8–12 h {{and}} [[Metronidazole]] 500 mg IV q8–12 h or 1500 mg q24h
::*Preferred regimen (1): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
:*'''2.3. Pseudomonas aeruginosa with more than 20% resistant to ceftazidime:'''
::*Preferred regimen (1): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (2): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (3): [[Meropenem]] 1 g IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (4): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (5): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (6): Imipenem-cilastatin 500 mg IV q6h {{or}} 1 g q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen (7): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Gentamicin]] 5–7 mg/kg IV q24h
::*Preferred regimen (8): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Tobramycin]] 5–7 mg/kg IV q24h
::*Preferred regimen (9): [[Doripenem]] 500 mg IV q8h {{and}} [[Piperacillin-tazobactam]] 3.375 g IV q6h {{and}} [[Amikacin]] 15–20 mg/kg IV q24h
::*Preferred regimen: [[Vancomycin]] 15–20 mg/kg IV q8–12 h
::*Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.
An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers anaerobicbacteria and gram-negativerods. Patients who have recurring acute attacks or who develop diverticulitis-associated complications, such as peritonitis, abscess, or fistula, require surgery, either immediately or on an elective basis.
Medical Therapy
Uncomplicated Diverticulitis
A 7-10 days of oral broad-spectrum antibiotic therapy is the first-line of therapy for acute uncomplicated diverticulitis.[1]
Hospital is indicated in all patients who are elderly, those with compromised immune systems, other comorbidities, cannot tolerate oral hydration, or fails to improve despite appropriate antibiotic therapy. The aim of hospital admission is bowel rest]], nasogastric tube placement, and parenteralantibiotics.[2]
Outpatients should be advised to follow a liquid diet for 2-3 days, after which a regular diet may be resumed slowly. Hospitalized patients are usually on NPO (Nothing Per Os) status with intravenous hydration, but a liquid diet may be allowed depending on the severity.
There is no scientific evidence that suggests that a low residue diet prevents the progression of diverticulosis to an acute case of diverticulitis.[3][4]
Routine colonoscopy is recommended after the resolution of the attack, to exclude colon cancer, or any other possible cause.[5]
Complicated Diverticulitis
Surgical intervention is the mainstay of therapy for cases of complicated acute diverticulitis which include:[6]
Peritonitis
Failed percutaneous drainage of an abscess
Enterocutaneous fistula formation
Bowel obstruction
References
↑Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN978-0-443-06839-3.
↑Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN978-0-443-06839-3.