How to manage stomach pain caused by chronic E. coli infection of the gallbladder?

Management of Stomach Pain Due to Chronic E. coli Infection of the Gallbladder

For chronic E. coli infection of the gallbladder causing stomach pain, definitive treatment with laparoscopic cholecystectomy plus appropriate antibiotic therapy is strongly recommended as the most effective approach to eliminate the source of infection and prevent recurrence. 1

Diagnostic Approach

• Ultrasound is the investigation of choice for suspected gallbladder infection, which may show pericholecystic fluid, distended gallbladder, edematous gallbladder wall, and possibly gallstones 1
• CT with IV contrast can provide additional information about the extent of infection and surrounding structures 1
• MRCP (Magnetic resonance cholangiopancreaticography) is recommended if common bile duct stones are suspected 1
• Laboratory tests should include white blood cell count, C-reactive protein, and liver function tests 1

Treatment Algorithm

1. Source Control (Primary Treatment)

• Laparoscopic cholecystectomy is the definitive treatment for chronic gallbladder infection, with open cholecystectomy as an alternative if laparoscopic approach is not feasible 1
• For patients who are poor surgical candidates due to multiple comorbidities, percutaneous cholecystostomy may be considered, though it is inferior to cholecystectomy in terms of outcomes 1

2. Antibiotic Therapy Based on Patient Status

For Non-Critically Ill, Immunocompetent Patients:

• Amoxicillin/Clavulanate 2g/0.2g every 8 hours is the recommended first-line therapy 1
• For patients with beta-lactam allergy, alternatives include:
  • Eravacycline 1 mg/kg every 12 hours, or
  • Tigecycline 100 mg loading dose, then 50 mg every 12 hours 1
• Duration: 4 days if source control (cholecystectomy) is adequate 1

For Critically Ill or Immunocompromised Patients:

• Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g every 6 hours or 16g/2g by continuous infusion 1
• For beta-lactam allergy: Eravacycline 1 mg/kg every 12 hours 1
• Duration: Up to 7 days based on clinical conditions and inflammatory markers 1

For Patients with Inadequate Source Control or Risk of ESBL-producing Enterobacterales:

• Ertapenem 1g every 24 hours or
• Eravacycline 1 mg/kg every 12 hours 1

For Septic Shock:

• Meropenem 1g every 6 hours by extended or continuous infusion, or
• Doripenem 500mg every 8 hours by extended or continuous infusion, or
• Imipenem/cilastatin 500mg every 6 hours by extended infusion, or
• Eravacycline 1 mg/kg every 12 hours 1

Special Considerations

• Ciprofloxacin has shown effectiveness in treating biliary tract infections and has good penetration into the biliary tract 2, 3, 4
• Patients who have ongoing signs of infection beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1
• For patients with prior cholecystectomy who develop recurrent biliary tract infections, consider bile acid malabsorption as a potential cause of symptoms 1
• Patients with persistent symptoms after treatment should be evaluated for possible complications or alternative diagnoses 1

Important Caveats

• Antibiotic therapy alone without source control (cholecystectomy) is associated with high recurrence rates in chronic gallbladder infections 1
• Empiric coverage for enterococci is not required for community-acquired biliary infections in immunocompetent patients 1
• Prolonged antibiotic therapy beyond recommended durations does not improve outcomes and may contribute to antimicrobial resistance 5
• Post-operative antibiotics are not recommended after uncomplicated cholecystectomy if source control is adequate 5
• In patients with prior cholecystectomy experiencing similar symptoms, consider bile acid malabsorption and consider 23-seleno-25-homotaurocholic acid scanning or serum 7α-hydroxy-4-cholesten-3-one to exclude this condition 1