Template:Uncomplicated Diverticulitis Antibiotics: Difference between revisions
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'''First, consider whether antibiotics are needed:''' | '''First, consider whether antibiotics are needed:''' | ||
*In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of '''supportive care alone''' (bowel rest, hydration, pain control) without antibiotics is reasonable<ref name="AGA2021">Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021;160(3):906-911.e1.</ref><ref name="ACP2022">Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.</ref> | *In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of '''supportive care alone''' (bowel rest, hydration, pain control) without antibiotics is reasonable<ref name="AGA2021">Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021;160(3):906-911.e1. doi:10.1053/j.gastro.2020.09.059</ref><ref name="ACP2022">Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.</ref> | ||
*Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation<ref name="AGA2021"/> | *Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation<ref name="AGA2021"/> | ||
'''If antibiotics are prescribed (4-7 day course preferred):'''<ref name="AGA2021"/> | '''If antibiotics are prescribed (4-7 day course preferred):'''<ref name="AGA2021"/> | ||
'''Preferred:''' | '''Preferred:''' | ||
* | *{{AntibioticDose|disease=Diverticulitis|drug=Amoxicillin/Clavulanate|dose=875/125mg PO Q8hrs x 5 days|context=Uncomplicated, Preferred}} (or Augmentin XR 2 tablets BID [each tablet 1gm [[Special:MyLanguage/amoxicillin|amoxicillin]] 62.5mg clavulanate])<ref name="Bala2017">Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.</ref><ref name="Gaber2021">Gaber CE, Kinlaw AC, Edwards JK, et al. Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies. Ann Intern Med. 2021;174(6):737-746. doi:10.7326/M20-6315</ref> | ||
**Equally effective as fluoroquinolone + metronidazole with lower ''[[Special:MyLanguage/Clostridioides difficile|C. difficile]]'' risk (especially in patients ≥65 years)<ref name="Gaber2021"/> | **Equally effective as fluoroquinolone + metronidazole with lower ''[[Special:MyLanguage/Clostridioides difficile|C. difficile]]'' risk (especially in patients ≥65 years)<ref name="Gaber2021"/> | ||
**Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)<ref name="FDA2016">FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.</ref> | **Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)<ref name="FDA2016">FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.</ref> | ||
'''Alternatives (penicillin allergy or intolerance):''' | '''Alternatives (penicillin allergy or intolerance):''' | ||
* | *{{AntibioticDose|disease=Diverticulitis|drug=Trimethoprim/Sulfamethoxazole|dose=one double-strength tablet BID|context=Uncomplicated, PCN allergy}} PLUS {{AntibioticDose|disease=Diverticulitis|drug=Metronidazole|dose=500mg PO Q8h x 5 days|context=Uncomplicated, PCN allergy}} | ||
* | *{{AntibioticDose|disease=Diverticulitis|drug=Metronidazole|dose=500mg PO Q8hrs|context=Uncomplicated, Alternative}} PLUS {{AntibioticDose|disease=Diverticulitis|drug=Ciprofloxacin|dose=500mg PO BID x 5 days|context=Uncomplicated, Alternative}} (reserve for patients without non-fluoroquinolone options)<ref name="FDA2016"/> | ||
* | *{{AntibioticDose|disease=Diverticulitis|drug=Moxifloxacin|dose=400mg PO QDaily|context=Uncomplicated, Alternative}} (same fluoroquinolone cautions apply)<ref name="Wilkins2013">Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.</ref> | ||
Latest revision as of 01:02, 21 March 2026
First, consider whether antibiotics are needed:
- In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of supportive care alone (bowel rest, hydration, pain control) without antibiotics is reasonable[1][2]
- Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation[1]
If antibiotics are prescribed (4-7 day course preferred):[1]
Preferred:
- Amoxicillin/Clavulanate 875/125mg PO Q8hrs x 5 days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])[3][4]
- Equally effective as fluoroquinolone + metronidazole with lower C. difficile risk (especially in patients ≥65 years)[4]
- Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)[5]
Alternatives (penicillin allergy or intolerance):
- Trimethoprim/Sulfamethoxazole one double-strength tablet BID PLUS Metronidazole 500mg PO Q8h x 5 days
- Metronidazole 500mg PO Q8hrs PLUS Ciprofloxacin 500mg PO BID x 5 days (reserve for patients without non-fluoroquinolone options)[5]
- Moxifloxacin 400mg PO QDaily (same fluoroquinolone cautions apply)[6]
- ↑ 1.0 1.1 1.2 Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021;160(3):906-911.e1. doi:10.1053/j.gastro.2020.09.059
- ↑ Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.
- ↑ Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
- ↑ 4.0 4.1 Gaber CE, Kinlaw AC, Edwards JK, et al. Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies. Ann Intern Med. 2021;174(6):737-746. doi:10.7326/M20-6315
- ↑ 5.0 5.1 FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.
- ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.