What is the first line antibiotic for Acute Cholecystitis?

From the Guidelines

The first-line antibiotic treatment for cholecystitis should be a Beta-lactam/beta-lactamase inhibitor combinations based regimen, such as piperacillin-tazobactam (3.375g IV every 6 hours) as monotherapy, due to its broad coverage against common biliary pathogens, including gram-negative organisms and anaerobes, as recommended by the 2019 guidelines 1. When choosing an antibiotic regimen, it is essential to consider the severity of the infection, patient factors such as renal function, and local resistance patterns.

• For patients with penicillin allergy, Fluoroquinolone-based regimens (in case of allergy to beta-lactams) can be used as an alternative, such as ciprofloxacin (400mg IV every 12 hours) plus metronidazole 1.
• The treatment duration is usually 4-7 days, depending on clinical response, and can be adjusted based on the patient's condition and the presence of any complications, as suggested by the 2024 recommendations 1.
• In mild cases, oral antibiotics like amoxicillin-clavulanate may be appropriate after initial IV therapy.
• Definitive treatment often requires cholecystectomy, with antibiotics serving to control infection before surgery or as the primary treatment in patients who cannot undergo surgery. The choice of antibiotic should be guided by the most recent and highest-quality evidence, and adjusted according to the individual patient's needs and the specific clinical context, as recommended by the 2019 guidelines 1 and the 2024 recommendations 1.

From the FDA Drug Label

INTRA-ABDOMINAL INFECTIONS Caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species. SURGICAL PROPHYLAXIS The preoperative administration of a single 1 gram dose of Ceftriaxone for Injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (e.g., vaginal or abdominal hysterectomy or cholecystectomy for chronic calculous cholecystitis in high-risk patients, such as those over 70 years of age, with acute cholecystitis not requiring therapeutic antimicrobials, obstructive jaundice or common duct bile stones)

The first line antibiotic for Cholecystitis is Ceftriaxone 2.

From the Research

First Line Antibiotic for Cholecystitis

• The choice of antibiotic for cholecystitis depends on several factors, including the severity of the disease, the presence of bacteremia, and the patient's overall health status 3.
• According to a study published in 1993, cefepime, a fourth-generation cephalosporin, is as effective as the combination of gentamicin and mezlocillin in preventing septic complications after cholecystectomy for acute cholecystitis 4.
• A 2021 study found that the empirical use of first-generation cephalosporins for mild-to-moderate acute cholecystitis without gallbladder perforation was not inferior to using second-generation cephalosporin for prophylaxis against postoperative infection 5.
• The Surgical Infection Society recommends the use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis, but advises against routine use in low-risk patients undergoing elective laparoscopic cholecystectomy 6.
• A 2024 review of antibiotic regimens in acute cholecystitis emphasizes the importance of early empirical antimicrobial therapy and source control of infection, with the choice of antibiotic depending on factors such as the severity of clinical manifestations and drug resistance 3.
• A 2016 systematic review found that antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy, with a pooled event rate of 20% for the need for emergency intervention or recurrence of the disease 7.

Antibiotic Options

• Cefepime, a fourth-generation cephalosporin, has been shown to be effective in preventing septic complications after cholecystectomy for acute cholecystitis 4.
• First-generation cephalosporins, such as cefazolin, may be used as an empirical treatment for mild-to-moderate acute cholecystitis without gallbladder perforation 5.
• Second-generation cephalosporins, such as cefoxitin, may also be used as an empirical treatment for acute cholecystitis 5.
• The choice of antibiotic should be guided by factors such as the severity of clinical manifestations, the presence of bacteremia, and drug resistance 3.