What are the recommended antibiotic treatments for acute cholecystitis?

From the Guidelines

Antibiotic treatment for acute cholecystitis should be administered for 4 days in immunocompetent patients and up to 7 days in immunocompromised or critically ill patients, with the option to extend based on clinical conditions and inflammation indices, as recommended by the Italian Council for the Optimization of Antimicrobial Use in 2024 1. The treatment approach for acute cholecystitis involves a combination of antibiotic therapy and source control, typically through laparoscopic cholecystectomy or open cholecystectomy as an alternative.

• The choice of antibiotic regimen should target common biliary pathogens, including enteric gram-negative organisms, enterococci, and anaerobes.
• For patients with significant comorbidities or those who are unfit for surgery, cholecystostomy may be considered as an alternative approach, although it is inferior to cholecystectomy in terms of major complications for critically ill patients.
• The duration of antibiotic therapy can be adjusted based on clinical response and the presence of ongoing signs of infection or systemic illness beyond 7 days of treatment, which may warrant further diagnostic investigation.
• It is essential to note that while antibiotics play a crucial role in managing the infection, definitive treatment usually requires source control through surgical or percutaneous interventions. The most recent guidelines from the Italian Council for the Optimization of Antimicrobial Use in 2024 provide the foundation for these recommendations, emphasizing the importance of tailored antibiotic therapy and source control in the management of acute cholecystitis 1.

From the FDA Drug Label

INTRA-ABDOMINAL INFECTIONS Caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species. SURGICAL PROPHYLAXIS The preoperative administration of a single 1 gram dose of Ceftriaxone for Injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (e.g., vaginal or abdominal hysterectomy or cholecystectomy for chronic calculous cholecystitis in high-risk patients, such as those over 70 years of age, with acute cholecystitis not requiring therapeutic antimicrobials, obstructive jaundice or common duct bile stones)

Ceftriaxone can be used for the treatment of intra-abdominal infections, which may include acute cholecystitis. The FDA label also mentions the use of Ceftriaxone for Injection as surgical prophylaxis for cholecystectomy in high-risk patients. However, it does not provide specific guidance on the use of ceftriaxone as a treatment for acute cholecystitis. 2

From the Research

Acute Cholecystitis Antibiotic Treatment

• The use of antibiotics in acute cholecystitis is crucial in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 3.
• The choice of antibiotic must be made considering factors such as the severity of the clinical manifestations, the onset of the infection, and the penetration of the drug into the bile 3.
• Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment 3.
• The most frequently isolated microorganisms in acute cholecystitis are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. 3.

Antibiotic Regimens

• The empirical use of first-generation cephalosporins for mild-to-moderate acute cholecystitis without gallbladder perforation was not inferior to using second-generation cephalosporin for prophylaxis against postoperative infection 4.
• A systematic review found that antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy 5.
• The current standard of care in acute cholecystitis is an early laparoscopic cholecystectomy with the appropriate administration of fluid, electrolyte, and antibiotics 6.

Special Considerations

• In patients who are not eligible for early laparoscopic cholecystectomy, it is suggested to delay surgery at least 6 weeks after the clinical presentation 7.
• Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD) 7.
• A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients 7.