Diverticulitis medical therapy: Difference between revisions
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{{Diverticulitis}} | {{Diverticulitis}} | ||
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==Overview== | |||
The mainstay of therapy for acute diverticulitis is usually conservative medical management, including [[bowel]] rest, [[IV]] [[fluid]] [[resuscitation]], and [[Broad-spectrum antibiotics|broad-spectrum antimicrobial therapy]] that covers [[Anaerobic organism|anaerobic]] [[bacteria]] and [[gram-negative]] [[Bacteria|rods]]. 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== | ==Medical Therapy== | ||
===Uncomplicated Diverticulitis=== | |||
* A 7-10 day course of oral, broad-spectrum [[antibiotic]] therapy is the first line of therapy for acute uncomplicated diverticulitis.<ref>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages = }}</ref> | |||
* Hospital admission is indicated for elderly patients and patients with multiple comorbidities, [[immunocompromised|compromised immune systems]], inability to tolerate oral [[hydration]], or failure to improve despite appropriate [[antibiotic therapy]]. | |||
* Hospitalized patients often require bowel rest, [[nasogastric tube]] placement, and [[parenteral]] [[antibiotics]].<ref>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 978-0-443-06839-3 | pages = }}</ref> | |||
* Outpatients should be advised to follow a liquid diet for 2-3 days, after which a regular diet may be resumed slowly. | |||
*There is no robust evidence that suggests that a [[low residue diet]] prevents the progression of [[diverticulosis]] to an acute case of diverticulitis.<ref name="pmid10215046">{{cite journal| author=Schechter S, Mulvey J, Eisenstat TE| title=Management of uncomplicated acute diverticulitis: results of a survey. | journal=Dis Colon Rectum | year= 1999 | volume= 42 | issue= 4 | pages= 470-5; discussion 475-6 | pmid=10215046 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10215046 }} </ref><ref name="titleManagement of uncomplicated acute diverticulitis - Journal Article: Diseases of Colon & Rectum">{{cite journal | [[Diseases of the Colon & Rectum]] |url=http://www.springerlink.com/content/f385544687u6g224/ |title=Management of uncomplicated acute diverticulitis |accessdate=2008-02-12 |volume = 42 | issue = 4 | date = April 1999 | doi = 10.1007/BF02234169 | pages = 470-475 | authors = Steven Schechter, Joan Mulvey and Theodore E. Eisenstat}}</ref> | |||
*Routine [[colonoscopy]] is recommended after the resolution of an acute diverticulitis to exclude [[colon cancer]] or any other underlying etiology.<ref name="pmid21904141">{{cite journal| author=Lau KC, Spilsbury K, Farooque Y, Kariyawasam SB, Owen RG, Wallace MH et al.| title=Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded? | journal=Dis Colon Rectum | year= 2011 | volume= 54 | issue= 10 | pages= 1265-70 | pmid=21904141 | doi=10.1097/DCR.0b013e31822899a2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21904141 }} </ref> | |||
=== | ====Antibiotic Regimens==== | ||
*'''1. Acute Diverticulitis''' <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:''' | |||
::*'''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-Clavulanate]] 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. | |||
==References== | ==References== | ||
{{ | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Surgery]] | [[Category:Surgery]] | ||
[[Category:Hematology]] | [[Category:Hematology]] | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Needs overview]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
Latest revision as of 21:26, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The mainstay of therapy for acute diverticulitis is usually conservative medical management, including bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy that covers anaerobic bacteria and gram-negative rods. 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 day course of oral, broad-spectrum antibiotic therapy is the first line of therapy for acute uncomplicated diverticulitis.[1]
- Hospital admission is indicated for elderly patients and patients with multiple comorbidities, compromised immune systems, inability to tolerate oral hydration, or failure to improve despite appropriate antibiotic therapy.
- Hospitalized patients often require bowel rest, nasogastric tube placement, and parenteral antibiotics.[2]
- Outpatients should be advised to follow a liquid diet for 2-3 days, after which a regular diet may be resumed slowly.
- There is no robust 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 an acute diverticulitis to exclude colon cancer or any other underlying etiology.[5]
Antibiotic Regimens
- 1. Acute Diverticulitis [6]
- 1.1. 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-Clavulanate 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.
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.
- ↑ 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.
- ↑ 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.