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Uncomplicated diverticulitis represents a localized infection, primarily by Gram-negative rods and anaerobes, mostly E. coli and B. fragilis. (Ambrosetti P, et al.)
Conservative (medical) treatment of acute uncomplicated diverticulitis is successful in 70-100% of patients. (Janes, et al. and Detry, et al.)
Some Common Choices of Antibiotics: Dual-Agent Coverage
Quinolone with metronidazole (Ciprofloxacin, 500 mg PO BID plus metronidazole, 500 mg PO BID)
Ciprofloxacin 400 mg IV q 12 hours plus metronidazole 500 mg PO/IV q 6-8 hours
Levofloxacin 500 mg IV daily plus metronidazole 500 mg PO/IV q 6-8 hours
Choices made in part with regard to history of drug allergies
Some Common Choices of Antibiotics: Single-Agent Therapy
Amoxicillin-clavulanate 875/125 mg PO BID
Ampicillin-sulbactam 3 g IV q 6 hours
Piperacillin-tazobactam 3.375 or 4.5 g IV q 6 hours
Ticarcillin-clavulanate 3.1 g IV q 4 hours
Imipenem 500 mg IV q 6 hours
Meropenem 1 g IV q 8 hours
Single- versus Dual-Antibiotic Therapy
Single and multiple antibiotic regimens are equally effective as long as both Gram-negative rods and anaerobes are covered adequately. (Kellum, et al.)
The Problem: Complicated Diverticulitis
Complications include obstruction, abscess formation, fistula formation or perforation.
Requires IV antibiotics plus surgery (usually Hartmann operation).
Antibiotics in Complicated Diverticulitis
Ampicillin 2 g IV q 6 hours plus gentamicin 1.5-2.0 g IV q 8 hours plus metronidazole 500 mg IV q 8 hours
Imipenem/cilastin 500 mg IV q 6 hours
Piperacillin-tazobactam 3.375 mg IV q 6 hours
Tigecycline, a new drug, has recently been approved for the treatment of intra-abdominal infections; it has not been shown to be superior to the traditional regimens.
Lots of choices- the goal is to cover GNRs and anaerobes and proceed to definitive surgery. No single regimen has been shown to be definitely superior to the others.
Krobot K, et al
425 patients who required surgery for community-acquired secondary peritonitis, including patients with complicated diverticulitis.
13% of patients did not receive appropriate antibiotics, defined as not covering all bacteria later isolated or not empirically covering typical aerobic and anaerobic organisms in the absence of culture results.
26% of appropriately treated patients and 30% of inappropriately treated patients had colonic sources of infection.
Resolution of infection with initial or step-down therapy after primary surgery was significantly less likely to occur (53% vs. 79%).
Failure of resolution of infection due to inadequate choice of antibiotics resulted in six-day prolongation of stay in hospital (20 versus 14 days total).
Schechter S, et al
Survey of 373 Fellows of the American Society of Colon and Rectal Surgeons surveyed regarding diagnosis and treatment of acute uncomplicated diverticulitis
Half of responders chose a single-drug regimen: second-generation cephalosporin (27%) or ampicillin/sulbactam (16%).
Single-therapy oral antibiotics at discharge were ciprofloxacin (18%), amoxicillin/clavulanate (14%), metronidazole (7%) and doxycycline (6%).
Combinations chosen were ciprofloxacin/metronidazole (28%) and TMP-SMX/metronidazole (6%). 21% chose various other antibiotics.
Antibiotic coverage must cover both Gram-negative rods and anaerobes, or infections will persist longer and prolong length of stay in hospital.
Single or multiple antibiotic regimens are equally effective as long as coverage is adequate- this equivalency amongst choices is probably why there aren’t any recent studies attempting to identify superior drugs!
Top choices by ASCRS Fellows include: ciprofloxacin plus metronidazole, ciprofloxacin alone and amoxicillin/clavulanate.
The dominant consideration regarding choice of antibiotics is coverage of GNRs and anaerobes!