From the Guidelines
Antibiotics are recommended for acute cholecystitis as part of the initial management, with the goal of reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, published in 2024 1, suggests that antibiotic therapy should be started promptly upon diagnosis and continued for 4-7 days, depending on the patient's clinical conditions and inflammation indices. The recommended antibiotic regimens include broad-spectrum antibiotics that cover gram-negative organisms, enterococci, and anaerobes, such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole.
Key Considerations
- The duration of antibiotic therapy may be shorter if the gallbladder is removed, as stated in the 2023 guidelines 1.
- For patients with severe illness or healthcare-associated infections, consider adding coverage for resistant organisms, as recommended in the 2020 guidelines 1.
- Cholecystectomy (gallbladder removal) is the definitive treatment for acute cholecystitis, ideally within 24-72 hours of diagnosis for uncomplicated cases, as suggested in the 2020 guidelines 1.
- Cholecystostomy may be an option for patients with multiple comorbidities and unfit for surgery, or patients who do not show clinical improvement after antibiotic therapy for 3-5 days, as stated in the 2023 guidelines 1 and 2024 guidelines 1.
Antibiotic Therapy
- The 2024 guidelines 1 recommend antibiotic therapy for 4 days in immunocompetent and non-critically ill patients if source control is adequate.
- For immunocompromised or critically ill patients, antibiotic therapy may be continued for up to 7 days based on clinical conditions and inflammation indices, as stated in the 2024 guidelines 1.
- Patients who have ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant a diagnostic investigation, as recommended in the 2024 guidelines 1.
From the Research
Antibiotic Use in Acute Cholecystitis
- The use of antibiotics in acute cholecystitis is a topic of ongoing research, with various studies investigating the effectiveness of different antibiotic regimens 2, 3, 4.
- A study published in 2023 found that bacterial infection is common in acute cholecystitis, and that second-generation cephalosporin was more effective than third-generation cephalosporin for Gram-negative microorganisms 2.
- Another study published in 2021 compared the use of first-generation and second-generation cephalosporins in patients with acute cholecystitis, and found that the incidence of postoperative infectious morbidities was similar between the two groups 3.
- A review published in 2024 emphasized the importance of antibiotic therapy in preventing surgical complications and limiting the systemic inflammatory response in patients with acute cholecystitis, and highlighted the need for periodic antibiotic susceptibility tests to select appropriate empirical antibiotics 4.
Recommendations for Antibiotic Use
- A systematic review published in 2016 found that antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy 5.
- A review published in 2022 noted that early laparoscopic cholecystectomy is the first-line therapy for acute cholecystitis, and that antibiotic therapy may be necessary in certain cases, such as in patients with severe or complicated disease 6.
- The choice of antibiotic should be based on factors such as the severity of the clinical manifestations, the onset of the infection, and the penetration of the drug into the bile, as well as any drug resistance 4.
Key Findings
- The most frequently isolated microorganisms in acute cholecystitis are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. 4.
- Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60% 4.
- Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment of acute cholecystitis 4.