Mild Diverticulitis can be treated without Antibiotics: 7 Evidence-based Facts.

You may be here because your doctor sent you home without prescribing an antibiotic for your diverticulitis flare-up!

That’s right; Antibiotics have been the cornerstone for treating acute diverticulitis.

But new scientific evidence found that antibiotics may not be necessary for mild, uncomplicated cases of acute diverticulitis.

Today, you will learn some basic facts and updated data about mild diverticulitis and antibiotic use in such a condition.

1. Mild versus severe or complicated diverticulitis.

Mild diverticulitis can be treated at home. There is no need for in-hospital treatment for mild diverticulitis unless you have complicated or severe diverticulitis.

So, before we dive into antibiotics for mild diverticulitis, we will mention some basics about the differences between mild and severe (or complicated diverticulitis).

The following are the criteria that differentiate severe or complicated diverticulitis:

A. Complicated diverticulitis (showed by CT abdomen):

• Frank perforation of the bowel (colon).
• A diverticular abscess (pocked filled with pus attached to the colon or freely inside the abdomen or pelvis.
• Fistula (track between the colon and adjacent organs such as the urinary bladder).
• Intestinal obstruction (symptoms include severe abdominal distension, absolute constipation, persistent vomiting, and abdominal pain).
• Massive diverticular bleeding.
• Low blood pressure (septic shock).

B. Uncomplicated, Severe diverticulitis:

• Evidence of sepsis: Temperature >38°C or <36°C, Heart rate >90, Respiratory rate >20 breath/min, white blood cells >12,000 or <4000, or CRP >15.
• Severe abdominal pain or tenderness (peritonitis).
• Age >70 years.
• Significant comorbid diseases include diabetes mellitus, coronary heart disease, liver cirrhosis, etc.
• Immunosuppressed patients.
• Being unable to tolerate eating or oral treatments.
• Non-compliant patients or lack of home care.
• Failed previous outpatient treatment.

C. Mild diverticulitis.

Patients with mild diverticulitis have typical symptoms and signs of acute diverticulitis but without the criteria of complicated or severe diverticulitis (mentioned above in sections A&B).

2. When are antibiotics needed for diverticulitis?

Antibiotics are needed for diverticulitis when:

• Complicated diverticulitis: abscess, fistula, perforation, intestinal obstruction, septic shock, etc.
• Uncomplicated severe diverticulitis (diverticulitis with severe pain, patients with a suppressed immune system, older than 70, or those with a long history of diabetes mellitus).
• Patients with uncomplicated diverticulitis with fever (>38°C) or hypothermia (<36°C).
• Patients with other signs of septicemia (respiratory rate >20, heart rate >90).
• White blood cell count >12,000 or <4,000).
• Selected patients with mild diverticulitis have significant diseases or a bad history of complicated diverticulitis.

Your doctor may or may not give antibiotics based on your unique condition and risk factors regarding mild diverticulitis. Recently, we no longer give antibiotics routinely for mild diverticulitis.

3. When are diverticulitis can be treated without antibiotics?

Diverticulitis can be treated without antibiotics at home if it’s mild and uncomplicated. Your doctor will decide based on your clinical status, CT abdomen, and laboratory findings.

The treatment of mild diverticulitis is often at home and based on two main lines:

• Pain control medications.
• Liquid diet (bowel rest).

After three days, you have to revisit your doctor to re-evaluate your condition.

The decision to treat mild diverticulitis without antibiotics is based on recent guidelines, which found no benefit from treating mild cases with antibiotics (reference).

After the re-check at the three days, your doctor may decide to add antibiotics if the symptoms don’t resolve or get worse.

4. Best antibiotics for mild diverticulitis treatment (and their dosage).

If your doctor decides to give you antibiotics at home for mild diverticulitis, he will often choose one or more options below.

NOTE: the doses below are for those who have normal liver and kidney functions. Your doctor may prescribe different doses based on your liver and kidney condition.

The following are the best antibiotics regimens for mild diverticulitis (reference):

• Ciprofloxacin (500 mg tablets every 12 hours) PLUS metronidazole (500 mg tablets every 8 hours).
• Levofloxacin (750 mg tablets once daily) PLUS metronidazole ( 500 mg tablets every 8 hours).
• Trimethoprim-sulfamethoxazole  (one double-strength tablet every 12 hours) PLUS metronidazole (500 mg/8h).
• Amoxicillin-clavulanate (875/125 mg every 8 hours.
• Augmentin XR (two tablets containing 1g amoxicillin & 62.5 mg clavulanate every 12 hours).
• Moxifloxacin (400 mg tablets once daily) is preserved for patients who cannot tolerate metronidazole and amoxicillin).

The duration of the antibiotic regimen for mild diverticulitis is often 10-14 days. However, your doctor may modify the dose or the duration based on your symptoms and comorbidities.

Your doctor usually needs to re-assess your condition at least once weekly until symptoms resolve during the antibiotic treatment.

6. Do oral antibiotics work for diverticulitis?

Oral antibiotics can be prescribed only in selected cases of mild diverticulitis. Also, patients who receive intravenous antibiotics often complete a 10-14 days course of oral antibiotics at home.

Oral antibiotics are helpful in many cases of diverticulitis when prescribed according to the needs. However, recent evidence suggests that oral antibiotics don’t provide added benefits in mild, uncomplicated cases of diverticulitis.

So, let your doctor decide whether antibiotics are good or not for your case.

7. Can you take long-term antibiotics to prevent diverticulitis?

The latest guidelines for diverticulitis don’t recommend taking long-term antibiotics to prevent diverticulitis occurrence or recurrence.

Some studies investigated the use of a locally-acting gut antibiotic to prevent diverticulitis. However, the results were controversial (reference).

In conclusion, no need to take long-term antibiotics to prevent diverticulitis unless prescribed by your doctor.

8. Can diverticulitis come back after antibiotics?

Diverticulitis may recur even after treatment with antibiotics. Following medical treatment with antibiotics for the first attack of diverticulitis, approximately one-third will have a second attack (reference).

The good news is that the recurrent attacks after treatment with antibiotics are often milder and uncomplicated.