Management of Gallbladder Empyema
Gallbladder empyema requires urgent laparoscopic or open cholecystectomy combined with appropriate antibiotic therapy, with the specific antibiotic regimen and duration determined by patient immune status, illness severity, and adequacy of source control. 1
Surgical Management: Source Control is Priority
Laparoscopic cholecystectomy is the definitive treatment, with open cholecystectomy as an alternative. 1 Empyema represents a form of complicated acute cholecystitis requiring urgent surgical intervention rather than delayed management. 1 Early operative intervention (within 7-10 days of symptom onset when possible) reduces infectious morbidity and mortality compared to delayed surgery. 2
Alternative for High-Risk Patients
Percutaneous cholecystostomy may be considered only for patients with multiple comorbidities who are unfit for surgery and do not show clinical improvement after antibiotic therapy. 1 However, this approach is inferior to cholecystectomy in terms of major complications, particularly in critically ill patients. 1 The cholecystostomy serves as a temporizing measure with plans for eventual cholecystectomy once the patient stabilizes. 3
Antibiotic Therapy: Tailored to Patient Status
Immunocompetent, Non-Critically Ill Patients
Amoxicillin/clavulanate 2g/0.2g every 8 hours is the first-line antibiotic when adequate source control is achieved. 1
- Continue antibiotics for 4 days post-operatively if source control is adequate 1
- For beta-lactam allergy: Eravacycline 1 mg/kg every 12 hours OR Tigecycline 100 mg loading dose then 50 mg every 12 hours 1
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) is recommended with adequate source control. 1
- Continue antibiotics for up to 7 days based on clinical conditions and inflammatory markers if source control is adequate 1
- For beta-lactam allergy: Eravacycline 1 mg/kg every 12 hours 1
Inadequate/Delayed Source Control or High ESBL Risk
Ertapenem 1g every 24 hours OR Eravacycline 1 mg/kg every 12 hours 1
Septic Shock
Use one of the following carbapenems with extended or continuous infusion: 1
- Meropenem 1g every 6 hours by extended infusion or continuous infusion
- Doripenem 500mg every 8 hours by extended infusion or continuous infusion
- Imipenem/cilastatin 500mg every 6 hours by extended infusion
- Eravacycline 1 mg/kg every 12 hours (alternative)
In cases of associated shock with biliary peritonitis, consider adding amikacin, and add fluconazole in fragile patients or cases of delayed diagnosis. 1
Diagnostic Approach
Ultrasound is the investigation of choice for suspected gallbladder empyema, showing: 1
- Pericholecystic fluid
- Distended gallbladder with edematous wall
- Gallstones (often impacted in cystic duct)
- Positive sonographic Murphy's sign
CT with IV contrast provides additional detail for surgical planning and detecting complications. 1 MRCP is reserved for suspected common bile duct stones. 1
Critical Pitfalls to Avoid
Do not delay surgical intervention beyond initial antibiotic stabilization in patients who are surgical candidates, as delayed operative intervention increases infectious morbidity and mortality. 2 Patients with ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant diagnostic investigation for inadequate source control or complications. 1
Avoid relying solely on percutaneous drainage in critically ill patients when cholecystectomy is feasible, as cholecystostomy is associated with higher major complication rates in this population. 1
Initiate broad-spectrum antibiotics within 1 hour if severe sepsis or septic shock is present, rather than delaying for cultures. 1 In hemodynamically stable patients without shock, a 6-hour delay for diagnostic sampling is acceptable. 1