What is the treatment for acute cholecystitis?

From the Guidelines

The treatment for acute cholecystitis should involve early laparoscopic cholecystectomy within 7 days of hospital admission and within 10 days of onset of symptoms, as this approach has been shown to reduce overall complications and hospital stay compared to delayed surgery 1.

Initial Management

Initial management includes:

• Bowel rest (nothing by mouth)
• Intravenous fluids for hydration
• Pain control with medications like morphine or hydromorphone
• Broad-spectrum antibiotics to cover enteric gram-negative organisms, enterococci, and anaerobes Common antibiotic regimens include piperacillin-tazobactam (3.375g IV every 6 hours), or a combination of ceftriaxone (1-2g IV daily) plus metronidazole (500mg IV every 8 hours), typically continued for 4-7 days.

Definitive Treatment

Definitive treatment is cholecystectomy, preferably performed laparoscopically.

• Laparoscopic cholecystectomy is the preferred treatment for acute cholecystitis, even in elderly patients 1.
• The laparoscopic approach should always be attempted at first, except in cases of absolute anesthetic contraindications and septic shock 1.
• Early laparoscopic cholecystectomy has been shown to be safe and effective, with a low complication rate and shortened hospital stay 1.

Alternative Treatments

For patients who are poor surgical candidates due to severe comorbidities or critical illness, percutaneous cholecystostomy (gallbladder drainage) may be performed as a temporizing measure.

• Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery 1.
• This approach allows for source control of the infection while avoiding the risks of surgery in high-risk patients.

Special Considerations

• In elderly patients, the evaluation of the risk should include mortality rate, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation by the use of frailty scores 1.
• The timing of laparoscopic cholecystectomy is controversial, but early laparoscopic cholecystectomy is recommended for patients who are fit to undergo surgery 1.

From the FDA Drug Label

ACUTE BACTERIAL OTITIS MEDIA caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta‑lactamase producing strains) or Moraxella catarrhalis (including beta-lactamase producing strains). SKIN AND SKIN STRUCTURE INFECTIONS caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii1, Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis1 or Peptostreptococcus species URINARY TRACT INFECTIONS (complicated and uncomplicated) caused by Escherichia coli, Proteus mirabilis, Proteus vulgaris, Morganella morganii or Klebsiella pneumoniae UNCOMPLICATED GONORRHEA (cervical/urethral and rectal) caused by Neisseria gonorrhoeae, including both penicillinase- and nonpenicillinase-producing strains, and pharyngeal gonorrhea caused by nonpenicillinase‑producing strains of Neisseria gonorrhoeae. PELVIC INFLAMMATORY DISEASE caused by Neisseria gonorrhoeae BACTERIAL SEPTICEMIA caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Haemophilus influenzae or Klebsiella pneumoniae. BONE AND JOINT INFECTIONS caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae or Enterobacter species INTRA-ABDOMINAL INFECTIONS caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species. MENINGITIS caused by Haemophilus influenzae, Neisseria meningitidis or Streptococcus pneumoniae SURGICAL PROPHYLAXIS The preoperative administration of a single 1 gm dose of Ceftriaxone for Injection, USP 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 treatment for acute cholecystitis may involve surgical procedures, and Ceftriaxone for Injection, USP can be used as surgical prophylaxis to reduce the incidence of postoperative infections in patients undergoing cholecystectomy.

• The preoperative administration of a single 1 gm dose of Ceftriaxone for Injection, USP may provide protection from most infections due to susceptible organisms throughout the course of the procedure 2.
• Ceftriaxone for Injection, USP has been shown to be effective against several bacterial organisms that may cause infections in the abdominal area, including Escherichia coli, Klebsiella pneumoniae, and Bacteroides fragilis. However, the treatment of acute cholecystitis should be guided by the severity of the disease and the presence of any underlying conditions, and may require a combination of antimicrobial therapy and surgical intervention.

From the Research

Treatment Options for Acute Cholecystitis

The treatment for acute cholecystitis typically involves a combination of medical and surgical interventions. The primary goal is to manage the infection, reduce inflammation, and prevent further complications.

Medical Management

• Patients with acute cholecystitis are usually hospitalized and treated with intravenous hydration and antibiotics covering enteric organisms 3.
• They should receive nothing by mouth and may require a nasogastric tube if ileus is present 3.
• Conservative management for 24 to 48 hours allows the inflammatory and infectious processes to "cool down" before surgery 3.

Surgical Management

• Cholecystectomy is the treatment of choice for acute cholecystitis, with laparoscopic cholecystectomy being the preferred operation due to its shorter hospital stay, less pain, and earlier return to productivity 3.
• Early cholecystectomy is preferred over delayed surgical management, as it leads to shorter hospital stays and quicker return to productivity 3.
• In patients who are poor surgical candidates, cholecystostomy can be performed via percutaneous catheter drainage of the gallbladder with the patient under local anesthesia 3.

Alternative Treatment Options

• Percutaneous cholecystostomy is an effective contribution to the treatment of acute cholecystitis in high-risk patients, allowing patients to recover from the acute event and undergo elective laparoscopic surgery at a later stage 4, 5.
• Endoscopic transpapillary drainage with or without gallstone dissolution has been demonstrated to be an effective alternative to surgery in high-risk patients with acute calculous cholecystitis 3.

Antibiotic Therapy

• Cefepime is as effective as the combination of gentamicin and mezlocillin in preventing septic complications after cholecystectomy for acute cholecystitis, with the advantage of fewer doses and no nephrotoxicity 6.
• Antibiotic therapy should be tailored to the individual patient's needs, taking into account the severity of the infection and the presence of any underlying medical conditions.

Timing of Surgery

• Delaying surgery may be justified in certain cases, such as in patients with severe comorbidities or those who are not good candidates for emergency surgery 7.
• However, early surgery is generally preferred, as it leads to better outcomes and shorter hospital stays 3, 7.