What is the recommended management for a patient with acute cholecystitis, presenting with right upper quadrant (RUQ) pain, positive Murphy's sign, ultrasonography (US) showing gallstones, and leukocytosis (elevated white blood cell count)?

Management of Acute Cholecystitis

This patient requires early laparoscopic cholecystectomy within 7 days of hospital admission and within 10 days of symptom onset, along with immediate initiation of antibiotic therapy. 1

Immediate Management

Antibiotic Therapy

For this immunocompetent, non-critically ill patient with uncomplicated cholecystitis:

• Start Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours 1
• Alternative if beta-lactam allergy: Eravacycline 1 mg/kg every 12 hours OR Tigecycline 100 mg loading dose then 50 mg every 12 hours 1
• Continue antibiotics until surgical intervention 1

Supportive Care

• Intravenous fluid resuscitation 2
• Bowel rest (NPO status) 2
• Analgesics that do not mask clinical signs 3

Surgical Intervention

Timing is Critical

Early laparoscopic cholecystectomy (ELC) should be performed as soon as possible, ideally within 72 hours of diagnosis, but no later than 7 days of hospital admission and 10 days from symptom onset. 1, 3, 2

The evidence strongly supports early intervention:

• ELC reduces total hospital stay by approximately 4 days compared to delayed surgery 1
• Return to work occurs approximately 9 days sooner with ELC 1
• Lower hospital costs and greater patient satisfaction 1
• Prevents recurrent symptoms and complications during the interval period 2

Surgical Approach

• Laparoscopic cholecystectomy is the first-line treatment 1
• Single-shot antibiotic prophylaxis if early intervention performed 1
• No postoperative antibiotics needed if source control is adequate and patient is immunocompetent 1
• Open cholecystectomy is an acceptable alternative if laparoscopic approach is not feasible 1

Postoperative Antibiotic Duration

For uncomplicated cholecystitis with adequate source control:

• No postoperative antibiotics required 1

If antibiotics were started preoperatively and source control is adequate:

• Continue for 2-4 days postoperatively in immunocompetent, non-critically ill patients 1

Important Clinical Caveats

When to Delay Surgery

If ELC cannot be performed within the optimal timeframe:

• Delay cholecystectomy to at least 6 weeks after clinical presentation 1, 2
• Continue antibiotic therapy for no more than 7 days 1
• This delayed approach is NOT recommended for immunocompromised patients 1

Signs of Complicated Cholecystitis

Monitor for features suggesting complicated disease:

• Palpable gallbladder mass 1
• Persistent fever or worsening clinical condition 1
• Pericholecystic fluid on imaging 1

If complicated cholecystitis develops, extend antibiotic therapy to 4 days postoperatively (or up to 7 days in immunocompromised/critically ill patients) 1

Alternative for High-Risk Patients

For patients with multiple comorbidities who are unfit for surgery and do not improve with antibiotic therapy:

• Percutaneous cholecystostomy may be considered 1
• However, this is associated with higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 4
• Should be reserved only for exceptionally high perioperative risk patients 4

Diagnostic Confirmation

The ultrasound findings (gallstones, positive Murphy's sign) combined with RUQ pain and leukocytosis (WBC 14.8) establish the diagnosis with high certainty 1. Additional imaging is not necessary unless:

• Common bile duct stones are suspected (consider MRCP) 1
• Complicated cholecystitis is suspected (consider CT with IV contrast) 1

Common Pitfall

Do not delay surgery beyond 7-10 days thinking the patient will "cool down" better with prolonged antibiotics. This approach increases recurrence rates and complications without improving surgical outcomes 1. If surgery cannot be performed early, it must be delayed to at least 6 weeks 1.