What is the treatment for an infected gallbladder (cholecystitis)?

Treatment of Infected Gallbladder (Acute Cholecystitis)

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the definitive treatment for acute cholecystitis, with single-dose antibiotic prophylaxis if surgery occurs within 24-48 hours and no postoperative antibiotics needed for uncomplicated cases. 1

Initial Diagnostic Workup

• Obtain right upper quadrant ultrasound as first-line imaging to confirm cholecystitis, looking for gallbladder wall thickening (>3mm), pericholecystic fluid, gallstones, and sonographic Murphy's sign 1, 2
• Order CT scan with IV contrast if ultrasound is inconclusive or if complications (perforation, abscess) are suspected 1
• Consider hepatobiliary scintigraphy (HIDA scan) when diagnosis remains uncertain after ultrasound, as it has the highest sensitivity for cystic duct obstruction 3, 4

Classification: Uncomplicated vs Complicated Cholecystitis

Uncomplicated Cholecystitis

• Right upper quadrant pain, positive Murphy's sign, fever without signs of perforation, abscess, or gangrenous changes 1

Complicated Cholecystitis

• Presence of gallbladder perforation, pericholecystic abscess, gangrenous cholecystitis, or emphysematous cholecystitis 1

Definitive Surgical Management

For Uncomplicated Cholecystitis

Perform early laparoscopic cholecystectomy within 7-10 days of symptom onset as this reduces hospital stay, complications, and recurrence compared to delayed surgery 1, 4

• Administer single-dose antibiotic prophylaxis only (amoxicillin/clavulanate 2g/0.2g IV) if surgery occurs within 24-48 hours 1, 2
• No postoperative antibiotics are required when source control is adequate and infection does not extend beyond the gallbladder wall 1, 5
• Open cholecystectomy remains a viable alternative in resource-limited settings or when laparoscopic approach is not feasible 1

For Complicated Cholecystitis

Proceed with laparoscopic or open cholecystectomy plus antibiotic therapy:

• For immunocompetent, non-critically ill patients: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours for 4 days post-operatively if source control is adequate 1, 5
• For critically ill or immunocompromised patients: Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g IV every 6 hours (or 16g/2g continuous infusion) for up to 7 days based on clinical response 1, 5

Antibiotic Selection by Patient Category

Non-Critically Ill, Immunocompetent Patients

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 1, 5
• Beta-lactam allergy: Eravacycline 1 mg/kg IV every 12 hours OR tigecycline 100mg loading dose then 50mg IV every 12 hours 1

Critically Ill or Immunocompromised Patients

• First-line: Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g IV every 6 hours 1, 5
• Beta-lactam allergy: Eravacycline 1 mg/kg IV every 12 hours 1, 5

Patients at Risk for ESBL-Producing Organisms

• Use carbapenem therapy: Ertapenem 1g IV every 24 hours 1, 5
• Alternative: Eravacycline 1 mg/kg IV every 12 hours 1, 5

Septic Shock

• Escalate to meropenem 1g IV every 6 hours by extended infusion, doripenem 500mg IV every 8 hours, or imipenem/cilastatin 500mg IV every 6 hours 5

Duration of Antibiotic Therapy

• Uncomplicated cholecystitis with early surgery: Single-dose prophylaxis only, discontinue within 24 hours post-operatively 1, 2, 5
• Complicated cholecystitis, immunocompetent: 4 days if adequate source control achieved 1, 5
• Complicated cholecystitis, critically ill/immunocompromised: Up to 7 days based on clinical response and inflammatory markers 1, 5
• Persistent infection beyond 7 days: Warrants diagnostic investigation for inadequate source control or complications 1, 5

Alternative Management for High-Risk Surgical Candidates

Percutaneous cholecystostomy is indicated for critically ill patients with multiple comorbidities who are unfit for surgery and do not improve after initial antibiotic therapy 1

• Provides temporary drainage as bridge to delayed cholecystectomy 1
• Continue antibiotics for 4 days post-procedure 1
• Note: Cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients, but remains safer than emergency surgery in unstable patients 1

Special Populations

Pregnant Women

• Early laparoscopic cholecystectomy is safe during all trimesters and reduces maternal-fetal complications (1.6% vs 18.4% with delayed management) 4

Elderly Patients (>65 years)

• Laparoscopic cholecystectomy reduces 2-year mortality (15.2%) compared to nonoperative management (29.3%) 4
• Age alone is not a contraindication to surgery 2

Adolescents

• Tolerate laparoscopic cholecystectomy well with excellent outcomes 2
• Use weight-based dosing: piperacillin/tazobactam 200-300 mg/kg/day of piperacillin component 5

Critical Pitfalls to Avoid

• Do not delay surgery beyond 10 days from symptom onset as this increases complications and conversion to open procedure rates 1, 2
• Do not provide prolonged antibiotic courses (>7 days) without investigating for inadequate source control or occult complications 1, 5
• Do not use ampicillin-sulbactam due to high E. coli resistance rates 6
• Recognize gallbladder perforation early (2-11% incidence, 12-16% mortality) and proceed with immediate surgical intervention 1
• Do not routinely cover for enterococci or MRSA in community-acquired infections unless specific risk factors present 5, 6

Coverage Considerations Not Routinely Required

• Enterococcal coverage: Not needed for community-acquired cholecystitis; reserve for healthcare-associated infections, immunocompromised patients, or those with valvular heart disease 5, 6
• Anaerobic coverage beyond standard regimens: Not required unless biliary-enteric anastomosis present 5, 6
• MRSA coverage: Only for known colonization or nosocomial infection with prior treatment failure 5, 6