What oral antibiotics are prescribed after a cholecystectomy (surgical removal of the gallbladder)?

From the Guidelines

Routine oral antibiotics after cholecystectomy are not recommended for most patients. For uncomplicated laparoscopic cholecystectomy, a single preoperative dose of antibiotics (such as cefazolin 1-2g IV) is sufficient, with no need for postoperative oral antibiotics 1. However, specific situations may warrant postoperative antibiotics, including complicated cases with perforation, bile spillage, or conversion to open surgery. In these cases, a short course of oral antibiotics like amoxicillin-clavulanate 875/125mg twice daily for 3-5 days may be prescribed. Patients with immunosuppression or those at high risk for infection might also benefit from postoperative antibiotics. The rationale for limiting antibiotic use is to prevent antimicrobial resistance, reduce side effects, and follow antimicrobial stewardship principles. Most uncomplicated cholecystectomies have a low infection risk (1-3%), and extending antibiotics beyond the perioperative period has not been shown to further reduce this risk 1. If signs of infection develop post-surgery (fever, increasing pain, purulent drainage), prompt evaluation and targeted antibiotic therapy would be indicated.

Some key points to consider:

• The use of postoperative antibiotics should be based on the individual risk factors for infection and the local resistance epidemiology 1.
• The choice of empiric antibiotic regimens should be based on the clinical condition of the patients and the individual risk for infection by resistant pathogens 1.
• In patients with uncomplicated intra-abdominal infections, such as uncomplicated appendicitis or cholecystitis, single doses have the same impact as multiple doses and postoperative antimicrobial therapy is not necessary if source control is adequate 1.
• Patients who have ongoing signs of peritonitis or systemic illness beyond 5-7 days of antibiotic treatment normally warrant a diagnostic investigation to determine whether additional surgical intervention is necessary to address an ongoing uncontrolled source of infection or antimicrobial treatment failure 1.

It's worth noting that, the most recent and highest quality study 1 recommends against the routine use of postoperative antibiotics when the focus of infection is controlled by cholecystectomy, which is in line with the general principle of limiting antibiotic use to prevent antimicrobial resistance and reduce side effects.

From the Research

Antibiotics Oral After Cholecystectomy

• The use of antibiotics after cholecystectomy is a topic of debate, with various studies providing different recommendations 2, 3, 4, 5, 6.
• According to the Surgical Infection Society Guidelines, routine use of peri-operative antibiotic agents is not recommended for low-risk patients undergoing elective laparoscopic cholecystectomy, but is recommended for patients undergoing laparoscopic cholecystectomy for acute cholecystitis 2.
• A meta-analysis found no significant benefit of extended antibiotic therapy in reducing surgical site infections after cholecystectomy for mild and moderate acute cholecystitis 3.
• A randomized controlled trial aimed to assess the benefits of postoperative antibiotics in patients with mild or moderate acute cholecystitis undergoing laparoscopic cholecystectomy, but the results are not yet available 4.
• A comparative study found that ceftibuten was more effective than amoxicillin/clavulanic acid for prophylaxis following gallbladder and biliary tract surgery, with no cases of postoperative infection in the ceftibuten group 5.
• An observational study found that antibiotic treatment lasting 4 days or less after early cholecystectomy was not associated with a higher incidence of surgical site infection, suggesting that treatment over 4 days provides no advantage in decreasing surgical site infection incidence 6.

Recommendations

• The Surgical Infection Society recommends against the use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis and in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis 2.
• The society also recommends a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis 2.

Duration of Antibiotic Therapy

• The optimal duration of antibiotic therapy after cholecystectomy is not well established, but studies suggest that treatment lasting 4 days or less may be sufficient 6.
• A study found that treatment over 4 days after early cholecystectomy provides no advantage in decreasing surgical site infection incidence 6.