Diverticulitis Empiric Therapy - An Overview

Introduction:

Empiric therapy can be defined as the antibiotic medication given to the patient during the period before receiving the results of microbiological tests such as blood culture and blood susceptibility tests based on clinical symptoms. Diverticulitis can be mild, moderate, or severe. Treatment of diverticulitis is based on significant clinical findings and the result of imaging studies. The core of the treatment includes antibiotic therapy, analgesia, and bowel rest. The American Gastroenterologist Association (AGA) suggests that the selective use of antibiotics in patients with acute uncomplicated diverticulitis should be preferred over routine antibiotics.

What Is Diverticulitis?

Diverticulitis is the inflammation of one or more pouches that are formed on the walls of the large intestine. Such pouched forms are known as diverticula, and the presence of diverticula in the large intestine is called diverticulosis. Just the mere presence of diverticula is not harmful. When these pouches get infected, it leads to diverticulitis. Sometimes, diverticulitis is present with mild symptoms, but it can also be severe with perforations and massive bowel infections.

What Are the Signs and Symptoms of Diverticulitis?

Diverticulosis is often asymptomatic and painless but may cause a few symptoms, like cramps on the left side of the abdomen that goes away after a bowel movement and bright red blood in the stools. Diverticulitis shows visible signs that include:

• Severe pain in the lower left side of the abdomen may be constant and persist for several days.

• Increased body temperature (fever).

• Nausea.

• Vomiting.

• Tenderness in the abdominal region.

• Constipation.

How Is Diverticulitis Diagnosed?

• Blood and Urine Test - To check for signs of infection.

• Stool Test - To check for the presence of abnormal bacteria.

• CT (Computed Tomography) Scan - To see infected diverticula and check for their severity.

• Barium Enema - This test shows problems of the large intestine more visible on X-rays.

• Colonoscopy - In this test, a thorough examination of the full length of the large intestine is done.

• Angiography - This test is helpful in case of rapid and heavy rectal bleeding. It helps in finding out the source of bleeding.

• Sigmoidoscopy - This test helps in a visual examination of the sigmoid colon and rectum using a thin, flexible tube with attached light and camera.

What Is the Difference Between Empiric Therapy and Definitive Therapy?

Initial therapy for infection is usually empiric and is guided by the visible signs and symptoms because the microbiological results get available after 24 to 72 hours. A common approach is to use broad-spectrum antibiotics as initial empiric therapy with the intention to cover the maximum possible pathogens commonly associated with the specific condition. This approach is needed as inadequate therapy for infections in hospitalized, critically ill patients associated with poor outcomes with significant morbidity and mortality and a more extended hospital stay. At the same time, definitive therapy is the antibiotic therapy given after getting the results of tests such as blood culture and antibiotic susceptibility tests.

What Are the Empiric Therapy Regimens for Diverticulitis?

1) In Patient With Mild to Moderate Diverticulitis:

In these patients, localized symptoms are seen without any manifestation of abscess, perforation, or significant comorbidity. Patients can be treated on an outpatient basis with regular follow-up. Oral antibiotics and a clear liquid diet for three to five days are recommended for these patients by the doctor. If the patient shows no improvement in two to three days, he or she is admitted to the hospital for further tests and treatment. Mild to moderate diverticulitis is treated with any of the following combinations:

• Ciprofloxacin - 750 mg twice a day to be taken by mouth plus Metronidazole 500 mg four times a day to be taken by mouth.

• Trimethoprim-Sulfamethoxazole - 160 mg/800 mg one DS (double strength) tablet twice a day to be taken by mouth plus Metronidazole 500 mg four times a day to be taken by mouth.

• Amoxicillin-Clavulanate - 875 mg/125 mg twice a day to be taken by mouth or Amoxicillin-Clavulanate extended-release 1000 mg/62.5 mg twice a day to be taken by mouth.

• Levofloxacin - 750 mg twice a day to be taken by mouth plus Metronidazole 500mg four times a day to be taken by mouth.

• Moxifloxacin - 400 mg daily to be taken by mouth. The duration for which this mediation is given is seven to ten days.

2) In Patients With Severe Diverticulitis:

Patients with severe diverticulitis will have generalized or focal peritonitis (inflammation of the inner lining of the abdominal wall), peridiverticular abscess (contained or walled-off infection in the abdomen), and signs of sepsis (fever, disorientation, difficulty breathing, extreme pain). Patients have been treated on an inpatient basis and may require surgical intervention. Supportive care is also suggested, which includes intravenous (IV) fluids, bowel rest, parenteral nutrition, and electrolyte imbalance. Severe diverticulitis is treated with any of the following combinations:

• Levofloxacin - 750 mg intravenously every 24 hours plus Metronidazole 500 mg intravenously every six hours or 1 g intravenously every 12 hours.

• Ciprofloxacin - 400 mg intravenously every 12 hours plus Metronidazole 500 mg intravenously every six hours or 1 g intravenously every 12 hours.

• Ceftolozane/Tazobactam - 1.5 g intravenously every eight hours plus Metronidazole 500 mg intravenously every eight hours.

• Ceftriaxone - One to two grams intravenously every 24 hours plus Metronidazole 500mg intravenously every six hours.

• Ampicillin-sulbactam - 3 g intravenously every six hours.

• Ampicillin - 2 g intravenously every six hours plus Metronidazole 500mg intravenously every six hours plus Amikacin, Tobramycin, or Gentamicin.

• Ampicillin - 2 g intravenously every six hours plus Metronidazole 500 mg intravenously every six hours plus Ciprofloxacin 400 mg intravenously every 12 hours or Levofloxacin 750 mg intravenous every 24 hours.

• Meropenem - 1 g intravenous every eight hours.

• Doripenem - 500 mg intravenous every eight hours.

• Piperacillin-Tazobactam - 3.375 g intravenously every six hours or 4.5 g intravenously every eight hours.

• Ertapenem - 1 g intravenously every 24 hours.

• Ticarcillin-Clavulanate - 3.1 g intravenously every six hours.

• Tigecycline - 100 mg intravenously first dose and then 50mg intravenously every 12 hours.

• Imipenem/Cilastatin - 500 mg intravenously every six hours. The duration of this therapy is seven days.

Conclusion:

The empiric therapy for patients with diverticulitis is given to avoid complications and reduce mortality and morbidity, as about 25% of the people with acute diverticulitis develop complications. Diverticulitis can be prevented by having regular bowel movements and avoiding straining and constipation. It can be done by eating more fibrous food, drinking plenty of water, and exercising regularly. People with a higher risk of developing diverticulitis, like the aged, obese, and those who smoke, should be more careful and take preventive steps.