What is the recommended management for a patient presenting with acute cholecystitis?

Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 72 hours of diagnosis (and up to 7-10 days from symptom onset) is the definitive treatment for acute cholecystitis, combined with initial antibiotic therapy that should be discontinued within 24 hours post-operatively if source control is adequate and the infection does not extend beyond the gallbladder wall. 1, 2, 3

Initial Diagnostic Approach

• Ultrasound is the first-line imaging modality for suspected acute cholecystitis, with key findings including pericholecystic fluid, distended gallbladder, edematous gallbladder wall (≥5mm), gallstones impacted in the cystic duct, and positive sonographic Murphy's sign 1, 2
• The combination of gallstones plus positive sonographic Murphy's sign has a 92% positive predictive value, while stones plus wall thickening has a 95% positive predictive value 1
• CT with IV contrast or MRCP should be reserved for evaluating complications or when common bile duct stones are suspected 1, 3

Antibiotic Selection Based on Patient Risk Stratification

Uncomplicated Cholecystitis in Stable, Immunocompetent Patients

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 1, 4, 3
• Alternative regimens: Ceftriaxone plus metronidazole, or ticarcillin/clavulanate 4, 3
• Anaerobic coverage is NOT required unless a biliary-enteric anastomosis is present 1, 4
• Enterococcal coverage is NOT required for community-acquired infections in immunocompetent patients 1, 4, 2

Complicated Cholecystitis or Critically Ill/Immunocompromised Patients

• First-line: Piperacillin/tazobactam 6g/0.75g loading dose, then 4g/0.5g IV every 6 hours OR 16g/2g by continuous infusion 1, 4, 3
• For documented beta-lactam allergy: Eravacycline 1 mg/kg IV every 12 hours OR tigecycline 100mg loading dose then 50mg IV every 12 hours 1, 3

Patients with Risk of ESBL-Producing Organisms

• Ertapenem 1g IV every 24 hours for patients with inadequate/delayed source control or high risk of community-acquired ESBL-producing Enterobacterales 1, 4
• Alternative: Eravacycline 1 mg/kg IV every 12 hours 1

Septic Shock

• Meropenem 1g IV every 6 hours by extended infusion or continuous infusion 1
• Alternatives: Doripenem 500mg IV every 8 hours by extended infusion, imipenem/cilastatin 500mg IV every 6 hours by extended infusion, or eravacycline 1 mg/kg IV every 12 hours 1

Healthcare-Associated Infections

• Add empiric anti-enterococcal coverage (ampicillin, piperacillin-tazobactam, or vancomycin based on susceptibility) for postoperative infections, patients previously receiving cephalosporins, immunocompromised patients, or those with valvular heart disease 1
• Add vancomycin for suspected MRSA only in patients known to be colonized or at high risk due to prior treatment failure and significant antibiotic exposure 1, 4

Duration of Antibiotic Therapy

Uncomplicated Cholecystitis with Early Surgery

• One-shot prophylaxis only if early intervention within 7-10 days; NO post-operative antibiotics 1, 4
• Discontinue antibiotics within 24 hours post-cholecystectomy unless infection extends beyond the gallbladder wall 1, 2, 3, 5

Complicated Cholecystitis with Adequate Source Control

• Maximum 4 days of antibiotics for immunocompetent, non-critically ill patients 1, 3, 5
• Up to 7 days for immunocompromised or critically ill patients, based on clinical response and inflammatory markers 1, 3
• Patients with ongoing signs of infection beyond 7 days warrant diagnostic re-evaluation 1

Delayed Treatment Strategy

• If early surgery is not possible, antibiotic therapy should continue for no more than 7 days, followed by planned delayed cholecystectomy at least 6 weeks later 1, 6
• This approach is NOT recommended for immunocompromised patients 1

Surgical Timing and Approach

Optimal Timing

• Early laparoscopic cholecystectomy within 72 hours of diagnosis is superior to delayed surgery, with benefits including shorter hospital stay, reduced recurrent complications, faster return to work, lower costs, and greater patient satisfaction 1, 2, 3, 6
• The acceptable window extends to 7-10 days from symptom onset 1, 2, 3
• Approximately 30% of conservatively treated patients develop recurrent complications and 60% ultimately require cholecystectomy 2, 6

High-Risk Patients

• Even high-risk patients (APACHE score 7-14) benefit from early laparoscopic cholecystectomy over percutaneous drainage, with the CHOCOLATE trial demonstrating lower mortality with surgery 1, 2
• Age >65 years is NOT a contraindication but is a risk factor for conversion to open surgery, along with male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 2

Patients Not Suitable for Surgery

• Percutaneous cholecystostomy should be reserved ONLY for patients who absolutely refuse surgery or have prohibitive physiological derangement requiring damage control 2
• Cholecystostomy is associated with significantly higher mortality compared to early surgery, even in high-risk patients 2
• If cholecystostomy is performed, continue antibiotics for 4 days 1

Microbiological Considerations

• Bile cultures are positive in 29-54% of acute cholecystitis cases 1
• Most common organisms: Escherichia coli, Klebsiella pneumoniae, Streptococcus spp., Enterococcus spp., and anaerobes (especially Bacteroides fragilis) 4, 7
• Obtain bile cultures in complicated cases and high-risk patients (immunocompromised, healthcare-associated infections) to guide targeted therapy 1, 3
• Adapt antibiotic regimen based on culture results in complicated cases 1

Common Pitfalls to Avoid

• Do NOT routinely cover enterococci or anaerobes in community-acquired cholecystitis unless specific risk factors are present 1, 4
• Do NOT continue antibiotics beyond 24 hours post-operatively for uncomplicated cases with adequate source control 1, 2, 3, 5
• Do NOT delay surgery beyond 72 hours unless the patient is truly unfit, as delayed surgery increases complications 1, 2, 3
• Do NOT use ciprofloxacin-based regimens as first-line due to increasing resistance, and reserve for beta-lactam allergic patients only 4
• Do NOT choose percutaneous drainage over surgery in high-risk patients who can tolerate anesthesia, as surgery has better outcomes 1, 2