What is the recommended duration of antibiotic therapy for cholecystitis (inflammation of the gallbladder) after percutaneous cholecystostomy (CCY) drain placement?

From the Guidelines

For cholecystitis after cholecystostomy tube placement, antibiotics should be continued for 4 days in immunocompetent patients with adequate source control, as recommended by the most recent guidelines 1. The exact duration of antibiotic therapy may vary depending on the patient's clinical condition, with some cases requiring up to 7 days of treatment 1.

• Key factors influencing the duration of antibiotic therapy include:
  • Clinical improvement, such as resolution of fever and normalization of white blood cell count
  • Decreasing drain output
  • Presence of comorbidities or critical illness
• Common antibiotic regimens for cholecystitis include piperacillin-tazobactam, ceftriaxone plus metronidazole, or ertapenem 1.
• The drain is typically removed when output decreases to less than 30mL per day and fluid appears non-purulent, which often occurs within 5-7 days.
• It is essential to note that patients who have ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant a diagnostic investigation 1.
• The most recent and highest quality study, published in 2024, supports the use of a 4-day antibiotic course in immunocompetent patients with adequate source control 1.

From the Research

Duration of Antibiotics for Cholecystitis after CCY Drain

• The optimal duration of antibiotics for patients with acute cholecystitis managed with percutaneous cholecystostomy (PC) is unknown, but studies suggest that antibiotics may be safely discontinued within one week of uncomplicated PC 2.
• A study published in the World Journal of Surgery found that patients who received short (≤7 day) courses of post-procedural antibiotics had similar outcomes to those who received long (>7 day) courses 2.
• The Surgical Infection Society recommends a maximum of four days of antibiotic agents for patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis 3.
• Another study published in the Journal of the Chinese Medical Association found that in moderate acute cholecystitis, patients receiving narrow-spectrum antibiotics had comparable clinical outcomes to those treated with broad-spectrum antibiotics 4.
• However, in severe acute cholecystitis, broad-spectrum antibiotics might still be necessary to rescue these patients 4.

Factors Influencing Antibiotic Duration

• The decision to extend or shorten antibiotic duration should be based on individual patient factors, such as the severity of cholecystitis, presence of comorbidities, and response to treatment 3, 2, 4.
• A study published in Surgical Endoscopy found that increasing age, male gender, coronary artery disease, cirrhosis, atrial fibrillation, diastolic congestive heart failure, and sepsis were associated with percutaneous cholecystostomy-tube placement 5.

Clinical Outcomes

• The clinical outcomes of patients with acute cholecystitis managed with percutaneous cholecystostomy and antibiotics are influenced by various factors, including the severity of cholecystitis, presence of comorbidities, and response to treatment 2, 4, 5.
• A study published in JAMA found that early laparoscopic cholecystectomy (performed within 1-3 days) is associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 6.