Guidelines
Diverticulitis

Diverticulitis

Definitions

Acquired outside the healthcare setting

  • More than 48 hours after admission, recent hospitalization, dialysis, or resident of long term care facility

  • Late onset (more than 5 days after admission) is associated with more resistant microorganisms

Localized to single organ without perforation

Extending into the peritoneal space, with peritonitis

Antibiotic therapy in preceeding 90 days or immune-compromised

Investigations

Modality depends on the clinical diagnosis

  • If a perforated viscus is suspected, plain X-ray (supine, upright, and lateral decubitus) should be done to look for free air

  • Ultrasound or CT is usually required to diagnose or characterize organ infections (e.g. cholecystitis, cholangitis, liver abscess) and abscesses

  • Blood cultures (2 aerobic & anaerobic sets) if patient is septic or immune-compromised
  • Intra-operative abscess/tissue samples or percutaneous aspirates for culture, even if the patient has been on antimicrobials
    • For increased yield, purulent fluid and/or tissue in a sterile container are preferred over swabs of fluid and tissue
  • Avoid taking cultures from drains/fistulae; the microbes isolated are likely to represent colonization and not clinical infection

Management

Source control is necessary; if symptoms present for a few days, can delay antibiotics if stable and pending source control procedure/specimen collection

Lack of clinical improvement should prompt further source control, rather than prolonging or changing antimicrobial therapy in the absence of culture results to support a change in antimicrobial management

  • Yeast are the only microorganism identified on Gram stain/culture from infected peritoneal fluid or tissue
  • Persistent intra-abdominal collections/infection and has had a prolonged course of antibiotics (tertiary peritonitis)
    • Fluconazole preferred in most cases
    • Echinocandin if non-albicans yeast or fluconazole exposure within past 30 days

Antibiotic recommendations below are empiric; tailor antibiotics to microbiology results

Day 2 Reassessment

Additional Information

  1. Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt). 2017 Jan;18(1):1-76.
  2. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015 May 21;372(21):1996-2005.
  3. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 133-64.