What is the recommended antibiotic coverage for cholecystitis?

Recommended Antibiotic Coverage for Cholecystitis

For cholecystitis, initial empiric antibiotic therapy should be based on severity, immune status, and healthcare association, with amoxicillin/clavulanate recommended for non-critically ill immunocompetent patients and piperacillin/tazobactam for critically ill or immunocompromised patients. 1

Patient Classification and Antibiotic Selection

Community-Acquired Cholecystitis

• For non-critically ill, immunocompetent patients: Amoxicillin/Clavulanate 2g/0.2g every 8 hours 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 patients with risk of ESBL-producing Enterobacterales: Ertapenem 1g every 24 hours or Eravacycline 1 mg/kg every 12 hours 1
• For patients with septic shock: Eravacycline 1 mg/kg every 12 hours 1

Healthcare-Associated Cholecystitis

• Consider anti-enterococcal coverage (particularly for E. faecalis) using ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility testing 2
• Empiric therapy against vancomycin-resistant E. faecium is not recommended unless the patient is at very high risk (e.g., liver transplant recipients) 2
• Consider MRSA coverage (vancomycin) only for patients who are known to be colonized or at risk due to prior treatment failure and significant antibiotic exposure 2

Duration of Antibiotic Therapy

• For uncomplicated cholecystitis with early surgical intervention: one-shot prophylaxis only, with no post-operative antibiotics 1
• For patients undergoing cholecystectomy: discontinue antibiotics within 24 hours unless there is evidence of infection outside the gallbladder wall 2, 3
• For complicated cholecystitis with adequate source control:
  • Immunocompetent, non-critically ill patients: 4 days of antibiotic therapy 1
  • Immunocompromised or critically ill patients: up to 7 days of antibiotic therapy 1

Special Considerations

• Anaerobic coverage is not indicated unless a biliary-enteric anastomosis is present 2
• Biliary infections are typically polymicrobial, including gram-negative bacteria (E. coli, Klebsiella, Pseudomonas), gram-positive bacteria (Enterococci, Streptococci), and anaerobes (Bacteroides) 4, 5
• The incidence of ciprofloxacin-resistant Enterobacteriales has shown a significant increasing trend, which should be considered when selecting antibiotics 6
• For surgical prophylaxis in high-risk patients (e.g., those over 70 years with acute cholecystitis), a single 1-gram dose of ceftriaxone may reduce postoperative infections 7

Common Pitfalls to Avoid

• Failing to adjust antibiotic therapy based on culture results when available 4
• Not considering biliary drainage when appropriate for cases with ongoing biliary obstruction 4
• Overuse of broad-spectrum antibiotics leading to antimicrobial resistance 4
• Prolonging antibiotic therapy unnecessarily after adequate source control has been achieved 3, 8

Microbiology Considerations

• Always obtain bile samples for culture to guide targeted antibiotic therapy 9
• The frequency of enterococci has declined, whereas Enterobacteriales (particularly E. coli) have increased over time 6
• Vancomycin-resistant E. faecium, carbapenem-resistant Enterobacteriales, and extended-spectrum beta-lactamase-producing Enterobacteriales have been recently observed 6