Should I start antibiotics for suspected acute cholecystitis?

From the Guidelines

Yes, you should start antibiotics for suspected acute cholecystitis. The most recent and highest quality study, published in 2019 in the World Journal of Emergency Surgery 1, recommends broad-spectrum antibiotics as adequate empiric therapy, which significantly affects outcomes in critical patients.

Key Points to Consider

• The recommended empiric antibiotic regimen includes piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours, as suggested by 1.
• Alternatively, ciprofloxacin 400mg IV every 12 hours plus metronidazole can be used for penicillin-allergic patients.
• Treatment should continue for 4-7 days, depending on clinical response, as indicated by 1.
• While starting antibiotics, arrange for prompt surgical consultation as cholecystectomy is the definitive treatment for most cases.
• Antibiotics are crucial because acute cholecystitis typically involves bacterial infection secondary to gallstone obstruction, with common pathogens including E. coli, Klebsiella, and anaerobes, as noted in 1.
• Monitor the patient's response with daily assessments of vital signs, abdominal examination, white blood cell count, and liver function tests, and adjust antibiotics based on culture results if available, as recommended by 1.

Important Considerations

• The choice of empirical antimicrobial regimen poses serious problems for the management of critically ill patients with intra-abdominal infections, and recent international guidelines recommend intravenous antibiotics within the first hour after severe sepsis and septic shock are recognized, as stated in 1.
• In patients with sepsis, an early correct empirical antimicrobial therapy has a significant impact on the outcome, as highlighted in 1.
• Elderly patients often take multiple drugs that may adversely interact with antibiotics and contribute to a significant increase in the incidence of toxic reactions, as mentioned in 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. 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)

Yes, you should start antibiotics for suspected acute cholecystitis, as ceftriaxone is indicated for the treatment of intra-abdominal infections, which includes acute cholecystitis 2.

• The drug label mentions that ceftriaxone can be used for the treatment of intra-abdominal infections caused by certain organisms.
• It also mentions the use of ceftriaxone as surgical prophylaxis for cholecystectomy in high-risk patients.

From the Research

Antibiotic Therapy for Suspected Acute Cholecystitis

• The decision to start antibiotics for suspected acute cholecystitis depends on the severity of the condition and the presence of certain risk factors 3, 4.
• Empirical antibiotic therapy is usually initiated to cover common biliary tract pathogens, including Enterobacteriaceae, such as Escherichia coli 3.
• The choice of antibiotic regimen may depend on the severity of the condition, with monotherapy with a ureidopenicillin (e.g., mezlocillin or piperacillin) being effective for patients with moderate clinical severity 3.
• In severely ill patients with septicaemia, an antibacterial combination is preferable 3.
• The duration of antibiotic therapy is typically limited to a few days, with the exception of patients with recurrent cholangitis or those who require long-term administration of antibacterials 3, 5.

Specific Recommendations

• For patients with acute cholecystitis, the Surgical Infection Society recommends the use of peri-operative antibiotic agents, but not routine use in low-risk patients undergoing elective laparoscopic cholecystectomy 5.
• A maximum of four days of antibiotic agents is recommended for patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis 5.
• For patients with mild acute calculus cholecystitis, intravenous antibiotic treatment may not be necessary, as it does not improve the hospital course or early outcome in most patients 6.

Antibiotic Regimens

• Effective antibiotic regimens for acute cholecystitis include piperacillin, cefazolin, cefuroxime, cefotaxime, and ciprofloxacin 3, 7.
• Ceftriaxone and cefoperazone have been shown to be equally effective in the treatment of acute cholecystitis, with ceftriaxone being simpler to administer and less expensive 7.