What antibiotics are recommended for treating cholecystitis in the third trimester of pregnancy?

From the Guidelines

For cholecystitis during the third trimester of pregnancy, the recommended approach includes administering antibiotics such as ampicillin, which has a low fetal risk category of B, as noted in the study by 1, and considering surgical intervention with laparoscopic cholecystectomy, as suggested by the most recent guideline from 1 and 1. The choice of antibiotic should be based on the severity of the disease and the potential risks to the fetus.

• Ampicillin is considered safe during pregnancy with a low fetal risk category of B, as indicated in the study by 1.
• The use of antibiotics should be complemented with supportive care, including IV hydration and pain management with acetaminophen or opioids if necessary, while avoiding NSAIDs in the third trimester due to the risk of premature ductal closure.
• Early consultation with both obstetrics and general surgery is crucial to coordinate optimal care for both mother and fetus, taking into consideration the gestational age and maternal condition.
• The timing of surgical intervention should be evaluated carefully, with elective surgery usually avoided in the first and third trimesters and ideally performed in the second trimester, as discussed in the study by 1.
• However, for biliary pain presenting late in the third trimester, postponing surgical intervention until delivery may be reasonable if it does not pose a risk to maternal or fetal health, as noted in the study by 1.

From the FDA Drug Label

Biliary Tract Infections: Due to E. coli, various strains of streptococci, P. mirabilis, and S. aureus. Perioperative Prophylaxis: The prophylactic administration of Cefazolin for Injection, USP preoperatively, intraoperatively, and postoperatively may reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated (e.g., vaginal hysterectomy and cholecystectomy in high-risk patients such as those older than 70 years, with acute cholecystitis, obstructive jaundice, or common duct bile stones).

Cefazolin can be used for the treatment of biliary tract infections, including cholecystitis. However, the label does not specifically address the use of cefazolin in the third trimester of pregnancy.

• The use of cefazolin in pregnant women, especially in the third trimester, should be based on the clinical judgment of the healthcare provider, considering the potential benefits and risks 2.

From the Research

Antibiotics for Cholecystitis in Third Trimester

• The use of antibiotics for cholecystitis in the third trimester is a critical aspect of management, as it can help prevent complications and improve outcomes 3.
• Initial therapy of acute cholecystitis is directed towards general support of the patient, including fluid and electrolyte replacement, correction of metabolic imbalances, and antibacterial therapy 3.
• Factors affecting the efficacy of antibacterial therapy include the activity of the agent against the common biliary tract pathogens and pharmacokinetic properties such as tissue distribution and the ratio of concentration in both bile and serum to the minimum inhibitory concentration for the expected micro-organism 3.
• Antimicrobial therapy is usually empirical, and initial therapy should cover the Enterobacteriaceae, in particular Escherichia coli 3.
• Coverage of anaerobes, in particular Bacteroides spp., is warranted in patients with previous bile duct-bowel anastomosis, in the elderly, and in patients in serious clinical condition 3.

Management Strategies

• A study published in 2023 compared the effectiveness of three different treatments for acute cholecystitis in the third trimester of pregnancy, including surgical, percutaneous transhepatic gallbladder drainage (PTGD), and conservative treatment groups 4.
• The study found that the readmission rate was lower in the surgical group than in the PTGD and conservative treatment groups, while the preterm delivery rate was lower in the PTGD group than in the surgical and conservative treatment groups 4.
• Another study published in 2022 found that laparoscopic cholecystectomy is the treatment modality of choice for symptomatic cholelithiasis and cholecystitis during pregnancy, but percutaneous cholecystostomy tube (PCT) can be used as a temporary management option during the peripartum period until interval laparoscopic cholecystectomy is performed 5.
• A review published in 2022 found that early laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications, a shorter length of hospital stay, and lower hospital costs 6.

Antibiotic Choices

• A study published in 1999 found that monotherapy with a ureidopenicillin, such as mezlocillin or piperacillin, is at least as effective as the combination of ampicillin plus aminoglycoside in patients with acute cholecystitis or cholangitis of moderate clinical severity 3.
• The study also found that therapy with aminoglycosides should not exceed a few days because the risk of nephrotoxicity seems to be increased during cholestasis 3.
• Other effective antibiotics for cholecystitis include cefazolin, cefuroxime, cefotaxime, and ciprofloxacin 3.