Antibiotic Regimens for Acute Cholecystitis
For acute cholecystitis, antibiotic selection should be stratified based on disease severity, with amoxicillin/clavulanate for stable immunocompetent patients and piperacillin/tazobactam for critically ill or immunocompromised patients, with specific alternatives for beta-lactam allergies and septic shock. 1
Patient Stratification and Initial Antibiotic Selection
Uncomplicated Cholecystitis in Stable, Immunocompetent Patients
- First choice: Amoxicillin/Clavulanate 2g/0.2g q8h 1
- If beta-lactam allergy:
- Eravacycline 1 mg/kg q12h OR
- Tigecycline 100 mg loading dose, then 50 mg q12h 1
Complicated Cholecystitis or Critically Ill/Immunocompromised Patients
- First choice: Piperacillin/Tazobactam 6g/0.75g loading dose, then 4g/0.5g q6h or 16g/2g by continuous infusion 1
- If beta-lactam allergy: Eravacycline 1 mg/kg q12h 1
Patients with Inadequate Source Control or Risk for ESBL-producing Enterobacterales
- Ertapenem 1g q24h OR
- Eravacycline 1 mg/kg q12h 1
Patients with Septic Shock
- First choice: Meropenem 1g q6h by extended/continuous infusion 1
- Alternatives:
- Doripenem 500mg q8h by extended/continuous infusion
- Imipenem/cilastatin 500mg q6h by extended infusion
- Eravacycline 1 mg/kg q12h 1
Duration of Antibiotic Therapy
Based on Clinical Scenario:
Uncomplicated cholecystitis with early cholecystectomy:
- One-shot prophylaxis only; no post-operative antibiotics 1
Uncomplicated cholecystitis with delayed cholecystectomy:
- Antibiotic therapy for no more than 7 days 1
Complicated cholecystitis with adequate source control:
- Immunocompetent patients: 4 days of antibiotics
- Immunocompromised/critically ill: Up to 7 days based on clinical condition and inflammatory markers 1
Severe (Tokyo Guidelines grade III) cholecystitis:
- Maximum 4 days of antibiotics 2
Important Considerations
Microbiological Trends
- Most common pathogens: Escherichia coli, Klebsiella pneumoniae, and anaerobes (especially Bacteroides fragilis) 1
- Increasing incidence of ciprofloxacin-resistant Enterobacteriales has been observed 3
- Recent emergence of vancomycin-resistant E. faecium, carbapenem-resistant Enterobacteriales, and ESBL-producing organisms 3
Source Control
- Early cholecystectomy (within 7-10 days of symptom onset) is the preferred treatment 1
- Antibiotic therapy alone without definitive source control is inadequate for most cases
- In high-risk surgical patients, percutaneous cholecystostomy may be considered, but is inferior to cholecystectomy in terms of major complications 1
Diagnostic Sampling
- Always obtain bile cultures during cholecystectomy to guide targeted antibiotic therapy 4
- Adjust to narrower spectrum agents once culture results are available 4
Special Populations
Elderly Patients
- Elderly patients from healthcare facilities may be colonized with multidrug-resistant organisms
- Intraoperative cultures should always be performed in these patients to guide therapy 1
- Consider broader initial coverage in elderly patients with healthcare-associated infections 1
Pediatric Patients
- For children, acceptable regimens include:
- Aminoglycoside-based regimen
- Carbapenem (imipenem, meropenem, or ertapenem)
- Beta-lactam/beta-lactamase inhibitor combination
- Advanced-generation cephalosporin with metronidazole 1
Common Pitfalls to Avoid
- Prolonged antibiotic therapy: Continuing antibiotics beyond 7 days without evidence of ongoing infection is not recommended 1
- Failure to obtain cultures: Always send bile for culture to guide targeted therapy 4
- Overtreatment of uncomplicated cases: Post-operative antibiotics are unnecessary after successful cholecystectomy for uncomplicated cholecystitis 1, 2
- Inadequate empiric coverage: Consider local resistance patterns when selecting initial therapy, particularly for healthcare-associated infections 1
- Delaying source control: Antibiotics alone without definitive surgical management is inadequate for most cases of acute cholecystitis