When is hospitalization indicated in patients with diverticulitis and which treatment options should be considered?

Updated: Aug 06, 2019
  • Author: Elie M Ghoulam, MD, MS; Chief Editor: BS Anand, MD  more...
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Answer

Hospitalization is required in the presence of evidence of severe diverticulitis, such as systemic signs of infection or peritonitis. Patients who are unable to tolerate oral hydration, whose condition is refractory to outpatient therapy (ie, persistent or increasing fever, pain, or leukocytosis after 2-3 days), who are immunocompromised, or who have comorbidities may also require hospitalization. Patients' pain may be severe enough to require parenteral narcotic analgesia.

Consider the following:

  • Initiate bowel rest and intravenous (IV) fluid hydration. Start broad-spectrum IV antibiotic coverage until culture results, if obtained, are available.

  • Monotherapy with beta-lactamase-inhibiting antibiotics or carbapenems provides broad antibacterial coverage and is appropriate for patients who are moderately ill and require inpatient admission. Such antibiotics include piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid, imipenem, or meropenem.

  • Multiple drug regimens are also appropriate options in the hospital setting and may consist of metronidazole and a third-generation cephalosporin or a fluoroquinolone. Such antibiotics include ceftriaxone, cefotaxime, ceftolozane/tazobactam, ciprofloxacin, or levofloxacin. Previously, gentamicin was recommended as part of a multidrug regimen; although this agent is still a reasonable choice, substitution with a third-generation cephalosporin or a fluoroquinolone has been advocated to avoid the risk of aminoglycoside nephrotoxicity.

  • For immunocompromised patients, imipenem or meropenem may be preferred over ertapenem for better enterococcal and pseudomonal coverage.

  • Pain management is important. Morphine is acceptable for analgesia and is preferred over meperidine owing to the adverse effects associated with meperidine. Although early recommendations for pain management favored meperidine based on a theoretical risk of affecting bowel tone and sphincters, randomized prospective studies comparing the narcotic options are not available. Use of nonsteroidal anti-inflammatory drugs and corticosteroids have been associated with a greater risk of colon perforation and should be avoided whenever possible. [5]  The AGA suggests against routinely advising avoidance of aspirin in those with a history of acute diverticulitis. [5]

  • Within 2-3 days of hospitalization, the patient's fever, pain, and leukocytosis should begin to resolve. The patient can then begin a clear liquid diet and advance as tolerated. If the patient tolerates oral intake and is clinically stable, they can be discharged to complete a 7-10-day course of PO antibiotic therapy.

  • If fever and leukocytosis do not resolve after 2-3 days of treatment or if serial examinations reveal worsening clinical signs or new peritoneal findings, a repeat CT scan of the abdomen is advisable to rule out an abdominal abscess or other complications. The WGO guidelines state that a lack of improvement should prompt clinical suspicion and an investigation for a phlegmon or an abscess. [1]

  • If a patient has a peridiverticular abscess that measures more than 4 cm in diameter (Hinchey stage II disease), CT scan-guided percutaneous drainage is indicated. This usually leads to a prompt (< 72 hour) reduction in pain, fever, and leukocytosis. Percutaneous drainage is also beneficial in that it may allow for elective surgery rather than emergency surgery, and it increases the likelihood of a successful one-stage procedure.

  • For abscess cavities containing gross fecal material or in the presence of a perforation, early surgical intervention is required.

IV tigecycline is no longer recommended for patients with a severe penicillin allergy due to an increased mortality risk relative to other antimicrobials used to treat severe infections. [40]  This higher all-cause mortality warranted a US Food and Drug Administration (FDA) Drug Safety Communication in September 2010, and the addition of a Black Box Warning to its prescribing information. [40]  In September 2013, an additional warning was added to the Black Box Warning to indicate that the increased risk of death with IV tigecycline occurred both with FDA-approved uses and nonapproved uses. [41]  Tigecycline is now reserved for use in situations when alternative treatments are not suitable. [41]

 


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