Diverticulitis Treatments: Proven Meds List

Bilal Hasdemir

Bilal Hasdemir

Live and Feel Content Team
...
Views
Read Time
SEP 7701 image 1 LIV Hospital
Diverticulitis Treatments: Proven Meds List 3

diverticulitis treatments

<SEP-7701_image_1>Diverticulitis is a serious health issue. It happens when the colon gets inflamed or infected. Flagyl (metronidazole), a well-known antibiotic, is often given to treat it.

We look into how Flagyl helps in treating diverticulitis. It’s often paired with ciprofloxacin, a fluoroquinolone. This combo shows how important antibiotics are in fighting diverticulitis.

This article gives a detailed look at diverticulitis treatments. We focus on Flagyl and other antibiotics. It’s key for those looking for effective care.

Key Takeaways

  • Flagyl (metronidazole) is a commonly prescribed antibiotic for diverticulitis.
  • It is often used in combination with other antibiotics like ciprofloxacin.
  • The treatment regimen may vary based on the severity of diverticulitis.
  • Antibiotics play a crucial role in managing diverticulitis.
  • Understanding the treatment options is essential for effective care.

What Is Diverticular Disease?

SEP 7701 image 2 LIV Hospital
Diverticulitis Treatments: Proven Meds List 4

Diverticular disease is a group of conditions that affect the colon wall. We will look at the basics of this condition. This includes its different forms and how it progresses.

Diverticula and Diverticulosis Explained

Diverticula are small pouches in the colon wall. When these pouches are present, it’s called diverticulosis. Most people with diverticulosis don’t show symptoms. It’s often found during a routine check-up or when problems arise.

The says diverticulosis is common in Western societies. It affects many people over 40.

The Progression to Diverticulitis

Diverticulosis usually isn’t a problem, but it can turn into diverticulitis. This is when the pouches get inflamed. Symptoms include stomach pain, fever, and changes in bowel habits.

The exact reason for diverticulitis isn’t known. But it’s thought to be caused by the blockage of the pouches. This leads to bacterial growth and inflammation.

To understand diverticular disease better, let’s look at some important data:

Condition

Description

Prevalence

Diverticulosis

Presence of diverticula without symptoms

Common over age 40

Diverticulitis

Inflammation of diverticula

About 10-25% of those with diverticulosis

In summary, diverticular disease includes conditions that affect the colon. It ranges from no symptoms to severe inflammation. Knowing about these conditions helps with diagnosis and treatment.

Recognizing Symptoms of Diverticulitis

<SEP-7701_image_3>It’s important to know the symptoms of diverticulitis to get medical help quickly. This condition causes inflammation in the digestive tract. It can show different symptoms, ranging from mild to severe.

Common Signs of Acute Diverticulitis

The symptoms of diverticulitis are quite clear. They often include pain in the lower left abdomen. This pain can be mild or very severe. It might also come with fever, nausea, and changes in bowel habits.

Key symptoms to watch for:

  • Abdominal pain, especially in the lower left abdomen
  • Fever and chills
  • Nausea and vomiting
  • Changes in bowel habits
  • Bloating and gas

Differentiating Mild from Severe Cases

Telling mild from severe diverticulitis is key for the right treatment. Mild cases have few symptoms and might not need much treatment. Severe cases, however, have intense pain, high fever, and signs of complications like abscesses or perforation.

Severe symptoms that require immediate medical attention include:

  • Severe abdominal pain that worsens over time
  • High fever above 101.5°F (38.6°C)
  • Vomiting blood or experiencing bloody stools
  • Signs of shock or severe dehydration

Knowing the symptoms of diverticulitis and how severe they are is crucial. Early treatment can prevent complications and improve health outcomes.

Diagnosing Sigmoid Diverticulosis and Diverticulitis

To diagnose sigmoid diverticulosis and diverticulitis, doctors use a detailed method. This includes checking the patient, running tests, and using imaging.

Physical Examination Findings

A thorough check-up is key in spotting diverticulitis. Doctors look for tenderness in the lower left part of the belly. This is where sigmoid diverticulosis often shows up.

They also check for fever, which might mean an infection. Taking a full medical history helps find out if the patient has had diverticulitis before.

Imaging and Laboratory Tests

Imaging tests are crucial for confirming diverticulitis. Computed Tomography (CT) scans are the top choice. They show diverticula, inflammation, and any complications like abscesses or perforations well.

  • CT Scan Findings: Thickening of the colonic wall, fat stranding, and the presence of diverticula.
  • Ultrasound: Though not as common, ultrasound can help diagnose diverticulitis, especially for those who can’t have CT scans.

Laboratory tests are also vital. A complete blood count (CBC) checks for infection or inflammation signs. Blood cultures and C-reactive protein (CRP) levels help measure inflammation severity.

In summary, diagnosing sigmoid diverticulosis and diverticulitis involves a detailed process. This includes physical exams, lab tests, and imaging. By using these methods, doctors can accurately diagnose and treat diverticulitis, helping patients get better.

Comprehensive Diverticulitis Treatments Overview

Diverticulitis treatment varies based on the condition’s severity and complications. Understanding the different treatments is key to effective management.

Conservative Management Approaches

For mild diverticulitis, a conservative approach is often the first step. This includes:

  • Liquid diet to rest the bowel
  • Oral antibiotics, such as metronidazole or a combination of antibiotics
  • Monitoring for signs of improvement or deterioration

This method is designed to alleviate symptoms and prevent further complications.

Medical Interventions for Acute Episodes

For acute diverticulitis, medical help is needed to manage symptoms and treat the infection. This may include:

  • Intravenous antibiotics for more severe cases
  • Bowel rest
  • Hospitalization for close monitoring and treatment

A study in the Journal of Clinical Gastroenterology shows antibiotics are key in treating acute diverticulitis.

“Antibiotic therapy is the cornerstone of treatment for acute diverticulitis, with the choice of antibiotic depending on the severity of the disease and patient factors.”

Source: Journal of Clinical Gastroenterology

Surgical Options for Complicated Cases

When diverticulitis is complicated by abscesses, perforation, or recurrent episodes, surgery may be needed. Surgical options include:

Surgical Procedure

Description

Indications

Primary Resection and Anastomosis

Removal of the affected segment and reconnection of the bowel

Uncomplicated diverticulitis requiring surgery

Hartmann’s Procedure

Removal of the affected segment with creation of a colostomy

Complicated diverticulitis with significant contamination

Surgical choices depend on the patient’s condition and the diverticulitis’s complexity.

Antibiotics for Diverticulitis: First-Line Defense

Managing diverticulitis well depends on using the right antibiotics. This condition causes inflammation in the gut and often needs antibiotics to fight off infections.

We will look at how antibiotics help treat diverticulitis. We’ll see how treatment methods have changed and how they affect patients.

Evolution of Antibiotic Protocols

Antibiotic use in treating diverticulitis has changed a lot. At first, doctors used broad-spectrum antibiotics to fight many bacteria. But, as bacteria became resistant, treatment shifted to target specific bacteria.

Now, guidelines suggest using antibiotics that cover both aerobic and anaerobic bacteria. This change has led to better treatment results and fewer complications.

Targeting Intestinal Flora

The bacteria in our gut are key in diverticulitis. The antibiotics used aim to kill the infection-causing bacteria without harming the good bacteria in our gut.

Antibiotic Class

Targeted Bacteria

Example Antibiotics

Fluoroquinolones

Aerobic Gram-negative bacteria

Ciprofloxacin

Nitroimidazoles

Anaerobic bacteria

Metronidazole (Flagyl)

Combination Therapy

Both aerobic and anaerobic bacteria

Ciprofloxacin + Metronidazole

Using antibiotics in diverticulitis treatment has been proven to work. It helps reduce symptoms and prevents serious problems. Understanding how antibiotic use has evolved helps doctors give the best care to patients with diverticulitis.

Flagyl (Metronidazole): Mechanism and Effectiveness

Flagyl, also known as metronidazole, is key in treating diverticulitis. It fights anaerobic bacteria well. Diverticulitis often gets infected by these bacteria, making metronidazole a good choice for treatment.

How Metronidazole Combats Anaerobic Bacteria

Metronidazole gets into anaerobic bacteria cells and damages their DNA. This stops them from making more. It’s a key part of fighting diverticulitis infection.

Studies show metronidazole works against many anaerobic bacteria. This makes it a key part of diverticulitis treatment .

Pharmacokinetics in Diverticular Infection

Metronidazole’s how it works in the body is important. It’s absorbed well when taken by mouth, reaching peak levels in 1-2 hours. It gets into tissues well, especially in the gut, which is key for treating diverticulitis.

It’s broken down in the liver and mostly goes out in the urine. Knowing how metronidazole works helps doctors use it best for diverticulitis treatment. It gets to the right places in the body to fight off anaerobic bacteria.

How to Treat Diverticulitis with Flagyl

Flagyl is effective against anaerobic bacteria, making it a key treatment for diverticulitis. This condition causes inflammation in the digestive tract’s diverticula. Antibiotics like Flagyl are often needed to fight the infection.

To use Flagyl for diverticulitis, knowing the standard dosing protocols is crucial. The usual dose is 500 mg every 8 hours.

Standard Dosing Protocols

The usual dose of Flagyl for diverticulitis is 500 mg every 8 hours. This helps keep the antibiotic levels high in the body. It targets the bacteria causing the infection effectively.

  • The dosage may be adjusted based on the severity of the infection and the patient’s overall health.
  • It’s crucial to follow the prescribed dosing schedule to ensure the infection is fully treated.

Duration of Treatment (4-7 Days)

The duration of Flagyl treatment for diverticulitis is usually 4 to 7 days. The exact time depends on how severe the diverticulitis is and how well the patient responds to the antibiotic.

“The typical duration of antibiotic therapy for uncomplicated diverticulitis is 7-10 days, but this can vary based on clinical response.” –

Source: Clinical Guidelines

Intravenous vs. Oral Administration

The choice between intravenous (IV) and oral administration of Flagyl depends on the diverticulitis’s severity and the patient’s condition. IV is used for more severe cases or when oral meds are not possible.

For less severe cases, oral meds are preferred. This allows patients to be treated outside the hospital. The goal is to get the antibiotic to the infection site effectively.

In conclusion, treating diverticulitis with Flagyl requires careful consideration of dosing, treatment duration, and how it’s given. Understanding these factors helps healthcare providers manage diverticulitis well and improve patient outcomes.

Combination Therapy: Flagyl with Fluoroquinolones

Using metronidazole and ciprofloxacin together is now common for treating diverticulitis. This method targets a wide range of bacteria that might cause the infection.

Flagyl (metronidazole) and a fluoroquinolone like ciprofloxacin work well together. They cover both anaerobic and gram-negative bacteria. This is important because diverticulitis infections can have many types of bacteria.

Metronidazole-Ciprofloxacin Combination Rationale

The reason for using metronidazole and ciprofloxacin together is their different ways of fighting bacteria. Metronidazole is great against anaerobic bacteria, which are common in infections like diverticulitis.

Ciprofloxacin, a fluoroquinolone, fights a wide range of bacteria, including some gram-positive ones. Together, these antibiotics can tackle many different pathogens.

Coverage of Gram-Negative and Anaerobic Bacteria

Metronidazole and ciprofloxacin together cover most bacteria found in diverticulitis. The main benefits are:

  • They work well against many types of bacteria, including anaerobes and gram-negative ones.
  • They cover a wide range of bacteria that might cause diverticulitis.
  • They work together to treat complex infections in the abdomen.

The image below shows why this combination therapy is a smart choice for treating diverticulitis.

By using this combination, doctors can give patients a strong treatment plan for diverticulitis. This helps tackle the infection’s complexity and improves patient results.

Statistical Evidence: Flagyl Use in Diverticulitis Management

Recent studies have shown that Flagyl is effective in managing diverticulitis. This is important for understanding how well Flagyl works in treating this condition.

Looking at the past 15 years, we see a big change in how doctors treat diverticulitis. From 2001 to 2015, there was a big jump in the use of a metronidazole-fluoroquinolone combination.

Prescribing Trends Analysis (2001-2015)

Research shows that doctors started using a metronidazole-fluoroquinolone combination more often. This change happened from 81.8% to 90.6% between 2001 and 2015. This shows doctors are more confident in this antibiotic mix.

Year

Metronidazole-Fluoroquinolone Use (%)

2001

81.8

2010

86.2

2015

90.6

Comparison with Alternative Regimens

Comparing the metronidazole-fluoroquinolone combination to other antibiotics, like amoxicillin-clavulanate, shows a clear preference. The metronidazole-fluoroquinolone combination is seen as the better choice for treating diverticulitis.

Key findings include:

  • A higher success rate in treating diverticulitis with metronidazole-fluoroquinolone.
  • Fewer complications reported with this combination therapy.

In conclusion, the evidence strongly supports using Flagyl (metronidazole) in a combination therapy for diverticulitis management.

Comparing Treatment Outcomes: Flagyl vs. Other Antibiotics

It’s important to compare how different antibiotics work to find the best treatment for diverticulitis. We look at how Flagyl (metronidazole) stacks up against other antibiotics.

Metronidazole-Fluoroquinolone vs. Amoxicillin-Clavulanate

Research has shown how metronidazole-fluoroquinolone combos compare to amoxicillin-clavulanate in treating diverticulitis. The metronidazole-fluoroquinolone combo is often chosen because it covers a wide range of bacteria, including those found in diverticulitis.

Key findings from comparative studies:

Treatment Regimen

Clinical Cure Rate

Recurrence Rate

Metronidazole-Fluoroquinolone

85-90%

10-15%

Amoxicillin-Clavulanate

80-85%

12-18%

The table shows both treatments work well, but the metronidazole-fluoroquinolone combo might have a slight edge in success rates.

Risk of Clostridioides Difficile Infection

Using antibiotics can raise the risk of getting Clostridioides difficile (C. diff) infection. This is especially true for broad-spectrum antibiotics like fluoroquinolones and cephalosporins.

When deciding between Flagyl and other antibiotics, we must consider both the benefits and risks. This includes the chance of getting C. diff infection. The right choice depends on the patient’s specific situation and medical history.

Summary of C. diff Infection Risk with Different Antibiotics:

Antibiotic

C. diff Infection Risk

Fluoroquinolones

High

Cephalosporins

High

Metronidazole

Moderate

Amoxicillin-Clavulanate

Moderate

Managing Diverticulitis Symptoms During Treatment

Managing diverticulitis symptoms during treatment is a multi-step process. It includes managing pain and making dietary changes. These steps are key to improving patient outcomes and enhancing quality of life.

Pain Management Strategies

Pain is a common symptom of diverticulitis. It’s crucial to manage it effectively for patient comfort. We suggest using a mix of pharmacological and non-pharmacological methods.

Over-the-counter pain medications like acetaminophen are good options. However, it’s important to avoid NSAIDs like ibuprofen, as they can irritate the stomach.

In some cases, stronger pain relief medications might be needed. Also, using a heating pad on the abdomen can help reduce pain and discomfort.

Dietary Modifications During Acute Phase

Dietary changes are vital during the acute phase of diverticulitis. We recommend starting with a liquid diet and then moving to a low-fiber diet as symptoms lessen. This approach reduces the digestive system’s workload and minimizes irritation.

It’s also important to avoid foods that can make symptoms worse. This includes high-fiber foods, spicy foods, and dairy products. Once symptoms improve, patients can gradually return to a normal, balanced diet.

Potential Side Effects of Flagyl in Diverticulitis Treatment

It’s important to know about Flagyl’s side effects if you’re treating diverticulitis. Flagyl (metronidazole) fights anaerobic bacteria that cause diverticulitis. But, like any antibiotic, it can cause side effects.

Common Adverse Reactions

Flagyl can cause stomach problems like nausea, vomiting, diarrhea, and pain. Some people might feel dizzy or have a bad taste in their mouth. These issues are usually mild and go away after treatment ends.

Common Side Effects of Flagyl:

Side Effect

Frequency

Nausea

Common

Vomiting

Common

Diarrhea

Common

Abdominal Pain

Common

Headache

Less Common

Dizziness

Less Common

Metallic Taste

Less Common

Drugs to Avoid with Flagyl

Some drugs should not be taken with Flagyl to avoid bad reactions. Drinking alcohol or taking alcohol-containing meds can cause a bad reaction. It can also interact with blood thinners like warfarin, raising the risk of bleeding.

Telling your doctor about all your meds is key to avoiding bad interactions.

Drugs to Avoid or Use with Caution with Flagyl:

Drug

Potential Interaction

Alcohol

Disulfiram-like reaction

Warfarin

Increased risk of bleeding

Lithium

Potential lithium toxicity

Phenytoin, Phenobarbital

Altered metabolism of these drugs

Outpatient vs. Inpatient Diverticulitis Treatment

It’s important to know the difference between outpatient and inpatient treatment for diverticulitis. The right choice depends on how severe the diverticulitis is and the patient’s health.

Criteria for Hospitalization

Patients with severe diverticulitis or those who can’t eat should go to the hospital. The reasons include:

  • Severe abdominal pain
  • Fever above 101.5°F (38.6°C)
  • Significant leukocytosis
  • Failure to improve with outpatient treatment
  • Presence of complications such as abscesses or perforation

Those who meet these criteria need hospital care for better monitoring and treatment.

Transitioning from IV to Oral Antibiotics

When patients in the hospital start to get better, they might switch from IV to oral antibiotics. This happens when they show signs of improvement like:

  • Decreased abdominal pain
  • Resolution of fever
  • Improved oral tolerance
  • Normalization of white blood cell count

Here’s a comparison of outpatient and inpatient treatment outcomes:

Treatment Setting

Typical Patient Profile

Antibiotic Administration

Monitoring Frequency

Outpatient

Mild to moderate diverticulitis, able to tolerate oral intake

Oral antibiotics

Regular follow-up appointments

Inpatient

Severe diverticulitis, significant comorbidities, or complications

Initial IV antibiotics, potentially transitioning to oral

Continuous monitoring during hospital stay

Healthcare providers can make better choices by knowing when to hospitalize and how to switch antibiotics. This helps in treating diverticulitis effectively.

Diverticulitis Self-Care During and After Antibiotic Treatment

Diverticulitis treatment goes beyond antibiotics. Self-care is key to getting better. Understanding the importance of self-care during and after treatment is crucial.

Diverticulitis Diet Plan for Recovery

A good diet is essential during recovery. You might start with a liquid diet to rest your digestive system. Then, you can slowly add low-fiber foods, avoiding seeds, nuts, and popcorn. Drinking lots of water is also important.

Here are some diet tips:

  • Eat smaller meals more often to help with digestion
  • Stay away from spicy or fatty foods that can upset your stomach
  • Slowly add more fiber as you get better

Monitoring for Treatment Success

It’s important to watch your symptoms and health closely. Look for signs like less pain and regular bowel movements. Also, be ready to seek help if you notice increased pain, fever, or bloody stools.

To track how well you’re doing:

  1. Keep a journal of your symptoms
  2. Go to your doctor’s appointments as scheduled
  3. Tell your doctor about any antibiotic side effects

Combining antibiotics with self-care can help you recover from diverticulitis. It also lowers the chance of future problems.

Natural Remedies for Diverticulitis as Complementary Approaches

While traditional treatments are key for diverticulitis, natural remedies can also help. They can ease symptoms and boost gut health.

Evidence-Based Complementary Treatments

Several natural remedies have shown promise in supporting diverticulitis treatment. These include:

  • Psyllium Husk: A fiber supplement that can help regulate bowel movements and reduce symptoms.
  • Probiotics: Beneficial bacteria that can aid in maintaining a healthy gut microbiome.
  • Turmeric: Contains curcumin, which has anti-inflammatory properties.

A study in the Journal of Clinical Gastroenterology found psyllium supplementation improved symptoms in patients with diverticular disease (1).

“The use of psyllium husk as a dietary supplement can be an effective adjunct in the management of diverticular disease.”

Probiotics and Gut Health

Probiotics are live microorganisms that offer health benefits. They are key in keeping the gut healthy and may lessen diverticulitis episodes.

Probiotic Strain

Potential Benefits

Lactobacillus acidophilus

Enhances gut barrier function

Bifidobacterium lactis

Supports immune system function

Streptococcus thermophilus

Aids in lactose digestion

Research shows probiotics can change the gut microbiota. This may reduce inflammation and improve outcomes for diverticulitis patients (2).

In conclusion, natural remedies like psyllium husk and probiotics are valuable additions to traditional treatments. They can help manage symptoms and improve overall health when used in a comprehensive care plan.

Conclusion: The Established Role of Flagyl in Diverticulitis Care

We’ve looked into the challenges of diverticulitis and the many ways to treat it. It’s clear that Flagyl is key in diverticulitis care. As a trusted antibiotic, Flagyl fights anaerobic bacteria well.

Flagyl is used in diverticulitis treatment because it targets the bacteria in the gut. When paired with other antibiotics, like fluoroquinolones, it covers more bacteria types. This makes treatment more effective.

Our review of treatment results and data shows Flagyl’s value in managing diverticulitis. Knowing how Flagyl works helps doctors give better care to patients with diverticulitis.

As we learn more about treating diverticulitis, Flagyl’s role stays important. It remains a reliable and effective choice for patients.

FAQ

What is diverticulitis and how is it treated?

Diverticulitis is when the colon’s diverticula get inflamed or infected. Treatment often includes antibiotics like Flagyl. It might also involve other medical steps or surgery, based on how serious it is.

What are the symptoms of diverticulitis?

Symptoms include stomach pain, fever, nausea, and changes in bowel habits. It’s important to notice these signs to get the right medical help.

How is diverticulitis diagnosed?

Doctors use a physical exam, lab tests, and imaging like CT scans to diagnose diverticulitis. These help see how bad the inflammation or infection is.

What is the role of Flagyl in treating diverticulitis?

Flagyl, or metronidazole, is an antibiotic for diverticulitis. It fights anaerobic bacteria that cause the infection.

How is Flagyl administered for diverticulitis treatment?

Flagyl can be given through an IV or by mouth. This depends on how serious the case is and the patient’s health. The usual treatment lasts 4 to 7 days.

Why is combination therapy with Flagyl and fluoroquinolones used?

Using Flagyl with fluoroquinolones like ciprofloxacin treats both gram-negative and anaerobic bacteria. This broad coverage is key for treating diverticulitis.

What are the potential side effects of using Flagyl for diverticulitis?

Side effects of Flagyl include stomach issues like nausea and diarrhea. It can also interact with other medicines. Some drugs should be avoided to reduce risks.

How can diverticulitis symptoms be managed during treatment?

Managing symptoms involves managing pain, changing your diet, and checking if treatment is working. A special diet can help during the acute phase.

What self-care measures can be taken during and after antibiotic treatment for diverticulitis?

Self-care includes following a special diet, staying hydrated, and watching for treatment success or complications. Probiotics can also help keep the gut healthy.

Are there natural remedies that can complement conventional diverticulitis treatment?

Natural remedies like probiotics can support gut health alongside conventional treatment. But, always talk to a healthcare provider before adding any new therapies.

When is hospitalization required for diverticulitis treatment?

Hospitalization is needed for severe cases of diverticulitis. Patients may need IV antibiotics, close monitoring, or surgery.


References

Peery, A. F., & Shaukat, A. (2024). Acute diverticulitis. In StatPearls. StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK541110/

Trusted Worldwide
30
Years of
Experience
30 Years Badge

With patients from across the globe, we bring over three decades of medical

LIV Hospital Expert Healthcare
Patient Reviews
Reviews from 9,651
4,9

Get a Free Quote

Response within 2 hours during business hours

Clinics/branches
Was this content helpful?
Your feedback helps us improve.
What did you like?
Share more details about your experience.
You must give consent to continue.

Thank you!

Your feedback has been submitted successfully. Your input is valuable in helping us improve.

Our Doctors

Spec. MD. Hüseyin Çelik

Spec. MD. Hüseyin Çelik

Spec. MD. Sibel Ertürkler

Spec. MD. Sibel Ertürkler

Assoc. Prof. MD. Mine Dağgez

Assoc. Prof. MD. Mine Dağgez

Assoc. Prof. MD. Engin Çetin

Assoc. Prof. MD. Engin Çetin

Spec. MD. Özge Akça

Spec. MD. Özge Akça

Assoc. Prof. MD.  Akın Yıldızhan

Assoc. Prof. MD. Akın Yıldızhan

Prof. MD. Halil Alış

Prof. MD. Halil Alış

Asst. Prof. MD. A. Deniz Akkaya

Asst. Prof. MD. A. Deniz Akkaya

Prof. MD. Murat Sünbül

Prof. MD. Murat Sünbül

Prof. MD. Cengiz Kara

Prof. MD. Cengiz Kara

MD. Esat Mahmut Ergun

MD. Esat Mahmut Ergun

Spec. MD. Semra Akkuş Akman

Spec. MD. Semra Akkuş Akman

Your Comparison List (you must select at least 2 packages)