Diverticulitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Mohamed Moubarak, M.D. [3]
Overview
An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest (ie, nothing by mouth), IV fluid resuscitation, and broad-spectrum antibiotics which cover anaerobic bacteria and gram-negative rods. However, recurring acute attacks or complications, such as peritonitis, abscess, or fistula may require surgery, either immediately or on an elective basis.
Upon discharge, patients may be placed on a low residue diet. This low-fiber diet gives the colon adequate time to heal without needing to be overworked. Later, patients are placed on a high-fiber diet. There is some evidence this lowers the recurrence rate.
Medical Therapy
Uncomplicated Diverticulitis
A 7-10 days of oral broad-spectrum antibiotic therapy is tried for acute uncomplicated diverticulitis.[1] Admission to the 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 parenteral antibiotics.[2]
Outpatients should be advised to use diet consist of liquids only for 2-3 days, after which the diet can be resumed slowly. hospitalized patients can be treated with either liquids, or NPO with intravenous hydration depending on the severity.
There is no scientific evidence suggests that avoidance of nuts and seeds prevents the progression of diverticulosis to an acute case of diverticulitis.[3][4] Further, in a survey of fellows of The American Society of Colon and Rectal Surgeons, although the majority of the surgeons responding to the survey favored adherence to a low residue diet, half of them still belief that there is no value in specifically avoiding seeds and nuts.[5]
Routine colonoscopy is recommended after the resolution of the attack, to exclude colonic neoplasia, or any other possible cause.[6]
Complicated Diverticulitis
Surgical intervention is required for complicated acute diverticulitis which include:[7]
- Peritonitis
- Failed percutaneous drainage of an abscess
- Enterocutaneous fistula formation
- Bowel obstruction
Antibiotic Regimen
- 1. Community-acquired infection in adults [8]
- 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 (4): Tigecycline 100 mg initial dose, THEN 50 mg IV q12h
- 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 [8]
- 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
- 2.2. Extended-spectrum B-lactamase-producing Enterobacteriaceae:
- 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
- 2.4.Methicillin-resistant Staphylococcus aureus (MRSA):
- 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.
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. ISBN 978-0-443-06839-3.
- ↑ 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. ISBN 978-0-443-06839-3.
- ↑ "Patient information: Diverticular disease". UpToDate. Retrieved 2008-02-12.
- ↑ Schechter S, Mulvey J, Eisenstat TE (1999). "Management of uncomplicated acute diverticulitis: results of a survey". Dis Colon Rectum. 42 (4): 470–5, discussion 475-6. PMID 10215046.
- ↑ Steven Schechter, Joan Mulvey and Theodore E. Eisenstat (April 1999). "Management of uncomplicated acute diverticulitis". 42 (4): 470–475. doi:10.1007/BF02234169. Retrieved 2008-02-12. Text " Diseases of the Colon & Rectum " ignored (help)
- ↑ Lau KC, Spilsbury K, Farooque Y, Kariyawasam SB, Owen RG, Wallace MH; et al. (2011). "Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded?". Dis Colon Rectum. 54 (10): 1265–70. doi:10.1097/DCR.0b013e31822899a2. PMID 21904141.
- ↑ Sheth AA, Longo W, Floch MH (2008). "Diverticular disease and diverticulitis". Am J Gastroenterol. 103 (6): 1550–6. doi:10.1111/j.1572-0241.2008.01879.x. PMID 18479497.
- ↑ 8.0 8.1 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "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. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.