Does acute cholecystitis require antibiotic therapy?

From the Guidelines

Yes, cholecystitis typically requires antibiotic treatment. Patients with acute cholecystitis should receive broad-spectrum antibiotics that cover gram-negative organisms, enterococci, and anaerobes. According to the 2017 WSES and SICG guidelines on acute calcolous cholecystitis in the elderly population 1, common regimens include:

• Beta-lactam/beta-lactamase inhibitor combinations based regimens
• Cephalosporins-based regimens
• Carbapenem-based regimens
• Fluoroquinolone-based regimens (in case of allergy to beta-lactams)
• Glycylcycline-based regimen

The choice of empirical antimicrobial regimen poses serious problems for the management of critically ill patients with intra-abdominal infections, and broad-spectrum antibiotics with good penetration into the presumed site of infection are recommended 1. In patients with sepsis, an early correct empirical antimicrobial therapy has a significant impact on the outcome 1.

Antibiotics should be started promptly after diagnosis and typically continued for 4-7 days, depending on clinical response. The duration may be shorter if the gallbladder is surgically removed. Prompt antibiotic therapy helps prevent complications such as gallbladder perforation, abscess formation, and systemic infection.

The decision for the empiric antimicrobial management of intra-abdominal biliary infections depends mainly on the presumed pathogens involved and risk factors for major resistance patterns and disease severity 1. Organisms most often isolated in biliary infections are the gram-negative aerobes, Escherichia coli and Klebsiella pneumonia and anaerobes, especially Bacteroides fragilis.

In patients who can tolerate oral feeding, to optimize antimicrobial therapy and minimize hospital stay, antibiotic therapy started initially intravenously may be switched to oral antibiotics 1.

Identifying the causative organism(s) is an essential step in the management of acute cholecystitis, and antibiotic therapy for 3–5 days is generally recommended for patients with complicated cholecystitis 1.

Overall, the management of acute cholecystitis requires prompt antibiotic therapy, and the choice of antibiotics should be guided by the most frequently isolated bacteria, taking into consideration antibiotic resistance and the clinical condition of the patient 1.

From the Research

Antibiotic Use in Cholecystitis

• The use of antibiotics in cholecystitis is a common practice, but the choice of antibiotic and its effectiveness can vary depending on the severity of the condition and the presence of specific microorganisms 2, 3, 4.
• Studies have shown that bacterial infection is common in acute cholecystitis, with Escherichia, Enterococcus, Klebsiella, and Enterobacter being the most frequent microorganisms 2.
• The effectiveness of different antibiotics can vary, with second-generation cephalosporin being more effective than third-generation cephalosporin for Gram-negative microorganisms, and vancomycin and teicoplanin being effective for Enterococcus 2.
• The use of empirical antibiotics can be tailored to the severity of the cholecystitis, with first-generation cephalosporins being suitable for mild-to-moderate cases without gallbladder perforation 3.

Specific Antibiotic Regimens

• A study comparing first-generation and second-generation cephalosporins found no difference in the incidence of postoperative infectious morbidities between the two groups 3.
• Another study found that narrow-spectrum antibiotics had comparable clinical outcomes to broad-spectrum antibiotics in patients with moderate acute cholecystitis after percutaneous cholecystostomy, but broad-spectrum antibiotics may still be necessary for severe cases 5.
• A systematic review found that antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy 6.

Diagnostic Approaches

• Metagenomic analysis can be used to rapidly detect potential pathogens and predict their antimicrobial susceptibility in patients with acute cholecystitis 4.
• This approach can provide valuable information for the selection of appropriate empirical antibiotics and can help guide treatment decisions 4.