- Author: Kamyar Shahedi, MD; Chief Editor: BS Anand, MD more...
Diverticulosis is treated with lifelong dietary modification. Antibiotics are used for every stage of diverticulitis. Empiric therapy requires broad-spectrum antibiotics effective against known enteric pathogens. For complicated cases of diverticulitis in hospitalized patients, carbapenems are the most effective empiric therapy because of increasing bacterial resistance to other regimens.
Empiric antimicrobial therapy is essential and should cover all pathogens likely to cause diverticulitis.
Active against various anaerobic bacteria. Enters cell, binds DNA, and inhibits protein synthesis, causing cell death.
Bactericidal antibiotic that inhibits bacterial DNA synthesis. Used for infections due to E coli, K pneumoniae, E cloacae, P mirabilis, P vulgaris, P aeruginosa, H influenzae, M catarrhalis, S pneumoniae, S aureus (methicillin susceptible), S epidermidis, S pyogenes, Campylobacter jejuni, Shigella species, and Salmonella typhi.
Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. The addition of clavulanate inhibits beta-lactamase–producing bacteria.
This agent is a good alternative antibiotic for patients allergic or intolerant to the macrolide class. It is usually well tolerated and provides good coverage to most infectious agents, but it is not effective against Mycoplasma and Legionella species. The half-life of an oral dosage form is 1-1.3 h. It has good tissue penetration but does not enter the cerebrospinal fluid.
For children >3 months, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in the presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding have been reported to decrease from 95% bound at plasma concentrations < 25 mcg/mL to 85% bound at 300 mcg/mL.
Third-generation cephalosporin with broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins, which, in turn, inhibits bacterial growth. Used for septicemia and treatment of gynecologic infections caused by susceptible organisms.
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
A cephalosporin antibiotic plus a beta-lactamase inhibitor. Indicated for use in combination with metronidazole for complicated intra-abdominal infections caused by Enterobacter cloacae, Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Bacteroides fragilis, Streptococcus anginosus, Streptococcus constellatus, and Streptococcus salivarius. Dose must be adjusted for reduced CrCl.
Moxifloxacin is the only fluoroquinolone that is FDA approved as monotherapy for the treatment of complicated intra-abdominal infections. Moxifloxacin, a broad-spectrum antibiotic, exhibits activity against Escherichia coli, Bacteroides fragilis, Streptococcus anginosus, Streptococcus constellatus, Enterococcus faecalis, Proteus mirabilis, Clostridium perfringens, Bacteroides thetaiotaomicron, or Peptostreptococcus species. Moxifloxacin is active against gram-positive organisms and anaerobes but is less active against Enterobacteriaceae and Pseudomonas species.
For pseudomonal infections and infections due to multidrug resistant gram-negative organisms.
Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Anti-pseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.
Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication.
Antipseudomonal penicillin and beta-lactamase inhibitor that provides coverage against most gram-positive and gram-negative bacteria and most anaerobes.
Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared with imipenem. Drugs of this class are a good choice for empiric therapy of GI-based infections in hospitalized patients with complicated conditions.
Tetracycline type antibiotic with broad coverage, used when the patient has a severe penicillin allergy. FDA approved for complicated intra-abdominal infections.
Aminoglycoside antibiotic used to cover gram-negative organisms.
Not the drug of choice (DOC). Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be given IV/IM.
Used for the treatment of multiple organism infections as in peritonitis when other agents are not appropriate.
Broad-spectrum penicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
[Guideline] World Gastroenterology Organisation (WGO). Practice Guidelines 2007. Diverticular disease. Available at http://www.worldgastroenterology.org/diverticular-disease.html. Accessed: 10 June 2011.
Shahedi K, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol. 2013 Dec. 11(12):1609-13. [Medline].
Shahedi K, Fuller G, Bolus R, et al. Progression from Incidental Diverticulosis to Acute Diverticulitis. Gastroenterol. 2012 May. 142(5) Suppl 1:S-144. [Full Text].
Strate LL, Modi R, Cohen E, Spiegel BM. Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol. 2012 Oct. 107(10):1486-93. [Medline].
Lahat A, Avidan B, Sakhnini E, Katz L, Fidder HH, Meir SB. Acute Diverticulitis: A Decade of Prospective Follow-up. J Clin Gastroenterol. 2013 Jan 16. [Medline].
Brandl A, Kratzer T, Kafka-Ritsch R, et al. Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?. Can J Surg. 2016 Jun 1. 59 (4):12915. [Medline].
Peery AF. Recent advances in diverticular disease. Curr Gastroenterol Rep. 2016 Jul. 18 (7):37. [Medline].
Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology. 2009 Jan. 136(1):115-122.e1. [Medline]. [Full Text].
[Guideline] Miller FH, Bree RL, Rosen MP, et al. Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria left lower quadrant pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. [Full Text].
Ricciardi R, Baxter NN, Read TE, Marcello PW, Hall J, Roberts PL. Is the decline in the surgical treatment for diverticulitis associated with an increase in complicated diverticulitis?. Dis Colon Rectum. 2009 Sep. 52(9):1558-63. [Medline].
Alonso S, Pera M, Pares D, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2009 Nov 10. [Medline].
Sanchez-Velazquez P, Grande L, Pera M. Outpatient treatment of uncomplicated diverticulitis: a systematic review. Eur J Gastroenterol Hepatol. 2016 Jun. 28 (6):622-7. [Medline].
Trivedi CD, Das KM. Emerging therapies for diverticular disease of the colon. J Clin Gastroenterol. 2008 Nov-Dec. 42(10):1145-51. [Medline].
Stollman N, Magowan S, Shanahan F, Quigley EM. A Randomized Controlled Study of Mesalamine After Acute Diverticulitis: Results of the DIVA Trial. J Clin Gastroenterol. 2013 Feb 18. [Medline].
Riansuwan W, Hull TL, Millan MM, Hammel JP. Nonreversal of Hartmann's procedure for diverticulitis: derivation of a scoring system to predict nonreversal. Dis Colon Rectum. 2009 Aug. 52(8):1400-8. [Medline].
Fleming FJ, Gillen P. Reversal of Hartmann's procedure following acute diverticulitis: is timing everything?. Int J Colorectal Dis. 2009 Oct. 24(10):1219-25. [Medline].
Rink AD, John-Enzenauer K, Haaf F, et al. Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption. Dis Colon Rectum. 2009 Oct. 52(10):1738-45. [Medline].
Crowe FL, Appleby PN, Allen NE, Key TJ. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ. 2011 Jul 19. 343:d4131. [Medline]. [Full Text].
Ambrosetti P, Robert JH, Witzig JA, Mirescu D, Mathey P, Borst F, et al. Acute left colonic diverticulitis in young patients. J Am Coll Surg. 1994 Aug. 179(2):156-60. [Medline].
Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of disease and outcome of complicated diverticular disease. Am J Surg. 2003 Dec. 186(6):696-701. [Medline].
Bordeianou L, Hodin R. Controversies in the surgical management of sigmoid diverticulitis. J Gastrointest Surg. 2007 Apr. 11(4):542-8. [Medline].
Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005 Jun. 140(6):576-81; discussion 581-3. [Medline].
Caterino JM, Emond JA, Camargo CA Jr. Inappropriate medication administration to the acutely ill elderly: a nationwide emergency department study, 1992-2000. J Am Geriatr Soc. 2004 Nov. 52(11):1847-55. [Medline].
Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, et al. Complicated diverticulitis: is it time to rethink the rules?. Ann Surg. 2005 Oct. 242(4):576-81; discussion 581-3. [Medline].
Dominguez EP, Sweeney JF, Choi YU. Diagnosis and management of diverticulitis and appendicitis. Gastroenterol Clin North Am. 2006 Jun. 35(2):367-91. [Medline].
Evans JP, Cooper J, Roediger WE. Diverticular colitis - therapeutic and aetiological considerations. Colorectal Dis. 2002 May. 4(3):208-212. [Medline].
Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med. 1998 May 21. 338(21):1521-6. [Medline].
Floch MH, White JA. Management of diverticular disease is changing. World J Gastroenterol. 2006 May 28. 12(20):3225-8. [Medline].
Freeman SR. Diverticulitis. McNally PR, ed. GI/Liver Secrets. Philadelphia, Pa: Hanley & Belfus; 1996. 332-338.
Hackethal V. Diverticulitis Surgery Often Avoidable, New Standard Needed. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/819310. Accessed: January 20, 2014.
Isselbacher KJ, Epstein A. Diverticular disease. Braunwald E, Longo DL, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. McGraw-Hill; 1998. 1648-1649.
Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007 Nov 15. 357(20):2057-66. [Medline].
Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ. 2006 Feb 4. 332(7536):271-5. [Medline].
Kazzi AA. Diverticular disease. Medscape Reference. 2006. [Full Text].
Kornitzer BS, Manace LC, Fischberg DJ, Leipzig RM. Prevalence of meperidine use in older surgical patients. Arch Surg. 2006 Jan. 141(1):76-81. [Medline].
Marinella MA, Mustafa M. Acute diverticulitis in patients 40 years of age and younger. Am J Emerg Med. 2000 Mar. 18(2):140-2. [Medline].
Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK. Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital. Dis Colon Rectum. 2000 Oct. 43(10):1383-9. [Medline].
Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, et al. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol. 2005 Jun. 17(6):649-54. [Medline].
Novak JS, Tobias J, Barkin JS. Nonsurgical management of acute jejunal diverticulitis: a review. Am J Gastroenterol. 1997 Oct. 92(10):1929-31. [Medline].
Oliver G, Lowry A, Vernava A, Hicks T, Burnstein M, Denstman F, et al. Practice parameters for antibiotic prophylaxis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2000 Sep. 43(9):1194-200. [Medline]. [Full Text].
Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol. 1975 Jan. 4(1):53-69. [Medline].
Patel DG, Thomson WG. Diverticulitis and diverticular hemorrhage. Clinical Practice of Gastroenterology. Philadelphia, Pa: Churchill Livingstone; 1999. 727-732.
Pemberton JH, Armstrong DN, Dietzen CD. Diverticulitis. Yamada T, Alpers DH, et al, eds. Textbook of Gastroenterology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1995. 1876-1888.
Poletti PA, Platon A, Rutschmann O, Kinkel K, Nyikus V, Ghiorghiu S, et al. Acute left colonic diverticulitis: can CT findings be used to predict recurrence?. AJR Am J Roentgenol. 2004 May. 182(5):1159-65. [Medline].
Rafferty J, Shellito P, Hyman NH, Buie WD. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. 2006 Jul. 49(7):939-44. [Medline].
Rampton DS. Diverticular colitis: diagnosis and management. Colorectal Dis. 2001 May. 3(3):149-53. [Medline].
Rao PM, Rhea JT, Novelline RA, Dobbins JM, Lawrason JN, Sacknoff R, et al. Helical CT with only colonic contrast material for diagnosing diverticulitis: prospective evaluation of 150 patients. AJR Am J Roentgenol. 1998 Jun. 170(6):1445-9. [Medline].
Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg. 1989 Mar. 26(3):133-89. [Medline].
Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A Systematic Review. JAMA Surg. 2014 Jan 15. [Medline].
Ripolles T, Agramunt M, Martinez MJ, Costa S, Gomez-Abril SA, Richart J. The role of ultrasound in the diagnosis, management and evolutive prognosis of acute left-sided colonic diverticulitis: a review of 208 patients. Eur Radiol. 2003 Dec. 13(12):2587-95. [Medline].
Schoetz DJ Jr. Uncomplicated diverticulitis. Indications for surgery and surgical management. Surg Clin North Am. 1993 Oct. 73(5):965-74. [Medline].
Schreyer AG, Furst A, Agha A, Kikinis R, Scheibl K, Scholmerich J, et al. Magnetic resonance imaging based colonography for diagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis. 2004 Sep. 19(5):474-80. [Medline].
Silverman ME, Shih RD, Allegra J. Morphine induces less nausea than meperidine when administered parenterally. J Emerg Med. 2004 Oct. 27(3):241-3. [Medline].
Wu JS, Baker ME. Recognizing and managing acute diverticulitis for the internist. Cleve Clin J Med. 2005 Jul. 72(7):620-7. [Medline].
Yacoe ME, Jeffrey RB Jr. Sonography of appendicitis and diverticulitis. Radiol Clin North Am. 1994 Sep. 32(5):899-912. [Medline].
Harvey J, Roberts PL, Schoetz DJ, et al. Do appendicitis and diverticulitis share a common pathological link?. Dis Colon Rectum. 2016 Jul. 59 (7):656-61. [Medline].
Wright GP, Flermoen SL, Robinett DM, Charney KN, Chung MH. Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis. Am J Surg. 2016 Jun. 211 (6):1035-40. [Medline].
Mali JP, Mentula PJ, Leppäniemi AK, Sallinen VJ. Symptomatic treatment for uncomplicated acute diverticulitis: a prospective cohort study. Dis Colon Rectum. 2016 Jun. 59 (6):529-34. [Medline].