|Last review: 19/01/2019|
|Next review: 19/01/2022|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guidelines for Investigation and Management of Acute Diverticulitis in Adults
Initial investigations required
Empirical antimicrobial treatment
Hospitalisation is required for patients with evidence of significant inflammation, unable to take oral fluids, older than 85 years or with significant co-morbidity (e.g. cardiorespiratory disease, immunosuppression etc.) [Evidence Level C]
[Evidence level C]
|Empirical Antimicrobial Treatment|
Empirical therapy at presentation is based on disease severity as determined by clinical history and examination. Disease severity is classified as:
A decision to treat with antibiotics should be reviewed if a radiological diagnosis of uncomplicated diverticulitis is made following a clinical diagnosis of complicated diverticulitis.
Acute diverticulitis with severe sepsis
Severe sepsis definition: An infection + SIRS + organ dysfunction e.g. hypotension, poor urine output, hypoxaemia, metabolic acidosis, clotting abnormalities or new confusion/altered mental status.
Complicated Acute Diverticulitis (based on clinical radiological findings) or diverticulitis + sepsis:
Uncomplicated Acute Diverticulitis (based on clinical radiological findings):
The best evidence for the antimicrobial management of diverticulitis comes from a study published in 2012. The study was a randomised controlled trial of antibiotics vs. no antibiotics in uncomplicated diverticulitis1.
The antibiotic group were initially treated with intravenous antibiotics (cephalsporins, carbapenems or piperacillin-tazabactem) followed by oral antibiotics (typically Ciprofloxacin /cefadroxil and Metronidazole ) for at least 7 days.
Patients in the study had on average
Many patients in the study therefore had a diagnosis of uncomplicated diverticulitis with SIRS.
This study found no differences in sigmoid resection rates, length of hospital stay or rate of recurrence.
Therefore, for the majority of patients the use of antibiotics is not of benefit and increases their risk of complications e.g. antibiotic resistance and Clostridium difficile infection.
This study had a number of exclusion criteria including pregnancy, immunosuppression and sepsis. This study does not therefore provide evidence applicable to all patient groups. Individual clinical assessment is therefore appropriate in the decision to treat patients with antibiotics.
Those without antibiotic therapy should be observed in hospital until surgically assessed as fit for discharge. Antibiotics may be started during this period of observation. Ongoing/progressive abdominal symptoms and fever as well as rising inflammatory markers are likely to prompt the initiation of antibiotics. This occurred in the study by Chabok in 10 of 299 (3.4%) patients allocated to receive no antibiotics. Therefore, in those patients where a reviewing surgeon, following a clinical assessment, is not satisfied a patient is safe for discharge and observation in hospital is not possible, the risk/benefit based decision to prescribe antibiotics may therefore move towards the use of antibiotics as opposed to observation.
|Duration of Treatment|
Complicated: Duration of therapy is dependent on clinical response (temperature, pain, CRP etc.)
Uncomplicated: Where it is indicated treatment is unlikely to be needed for more than 5 days. [Evidence Level C]
Luminal investigation should be undertaken after approximately 6/52 to rule out colonic malignancy.
|Switch to oral agent(s)|
Antibiotic route of administration should be reviewed at 48 hours.
Antimicrobial treatment of Acute Diverticulitis
|Target patient group:||Adults|
|Target professional group(s):||Secondary Care Doctors
- Chabok A. (2012). Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-539.
- Dan Med J. 2012 May;59(5):C4453. Danish national guidelines for treatment of diverticular disease. Andersen JC, Bundgaard L, Elbrønd H, Laurberg S, Walker LR, Støvring J.
- Janes, S. (2006). "Management of diverticulitis." BMJ 332: 271-275.
- Mizuki, A. (2005). "The out-patient management of patients with acute mild-to-moderate colonic diverticulitis." Aliment Pharmacol Ther 21: 889-897.
- Rafferty, J. (2006). "Practice Parameters for Sigmoid Diverticulitis." Dis Colon Rectum 49: 939-944.
- Salzman, H. (2005). "Diverticular Disease: Diagnosis and Treatment." American Family Physician 72(7): 1229-1234.
- Stollman, N. (1999). "Diagnosis and Management of Diverticular Disease of the Colon in Adults." THE AMERICAN JOURNAL OF GASTROENTEROLOGY 94(11): 3110-3121.
- Szojda, M. (2007). "Review article: management of diverticulitis." Aliment Pharmacol Ther 26(S2): 67-76.
- Sigmoid Diverticulitis: a systemic review. Arden M. Morris, Scott E. Regenbogen, Karin M. Hardiman, Samantha Hendren, JAMA. 2014;311(3):287-297. doi:10.1001/jama.2013.282025.
- Sigmoid Diverticulitis: A Systematic Review Arden M. Morris, Scott E. Regenbogen, Karin M. Hardiman, Samantha Hendren, JAMA. 2014;311(3):287-297.
- Management of acute uncomplicated diverticulitis without antibiotics: a single centre cohort study Nina Brochmann, Johannes Schultz, Gunn Signe Jakobsen, Tom Øresland Colorectal Disease 2016, accepted article
Improving Antimicrobial Prescribing Group
LHP version 1.1
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