Antibiotics for Uncomplicated Gallstones (Cholelithiasis)
Antibiotics are NOT indicated for uncomplicated gallstones (cholelithiasis) without evidence of acute inflammation or infection. 1
Key Distinction: Cholelithiasis vs. Cholecystitis
The critical decision point is whether the patient has simple gallstones (cholelithiasis) or acute inflammation (cholecystitis):
Uncomplicated Cholelithiasis (Simple Gallstones)
- No prophylactic antibiotics are needed for elective laparoscopic cholecystectomy in low-risk patients 2, 1
- Bile is typically sterile in uncomplicated cholelithiasis—only 10% of patients without risk factors have positive bile cultures 3
- A prospective randomized trial of 250 patients showed no benefit from prophylactic antibiotics (infection rate 0.8% with antibiotics vs. 3.3% without; not statistically significant) 2
- No postoperative antibiotics are required after elective cholecystectomy for symptomatic cholelithiasis 1
When Antibiotics ARE Indicated
Antibiotics become necessary when any of the following are present:
Acute Cholecystitis (inflammation/infection):
- Right upper quadrant pain with fever, leukocytosis, or positive Murphy's sign 4
- Ultrasound showing gallbladder wall thickening, pericholecystic fluid, or distension 4
- Start empiric antibiotics immediately 5, 6
Risk Factors for Infected Bile (Bactibilia):
- Age >70 years 3
- Common bile duct stones (choledocholithiasis) 5, 3
- Emergency surgery 3
- Acute cholecystitis 3
- All patients with these risk factors (100%) had positive bile cultures in one study, compared to only 30% without risk factors 3
Antibiotic Regimen When Indicated
For acute cholecystitis in stable, immunocompetent patients:
- Amoxicillin/Clavulanate 2g/0.2g IV every 8 hours as first-line 6, 4
- Covers the most common pathogens: E. coli, Klebsiella pneumoniae, and Bacteroides fragilis 6
For critically ill or immunocompromised patients (including diabetics):
Duration:
- Stop antibiotics within 24 hours after cholecystectomy if infection is confined to the gallbladder wall 5, 6, 1
- A prospective trial of 414 patients showed no benefit from continuing postoperative antibiotics (infection rate 17% with antibiotics vs. 15% without; p>0.05) 6
- For complicated cholecystitis with adequate source control: 4 days maximum for immunocompetent patients, up to 7 days for immunocompromised 6, 1
Common Pitfalls to Avoid
Do NOT give antibiotics for:
- Asymptomatic gallstones discovered incidentally 7
- Elective cholecystectomy in low-risk patients without inflammation 2, 1
- Routine prophylaxis "just in case" during uncomplicated laparoscopic cholecystectomy 2
Do NOT continue antibiotics postoperatively when:
- Early cholecystectomy (within 7-10 days) was performed 6, 1
- Infection was confined to the gallbladder wall 6
- Source control was adequate 5, 6
Bile or gallstone spillage during surgery:
- Does not require antibiotics 8
- A study of 481 patients with intraoperative spill showed no difference in infectious complications between those receiving antibiotics (8%) versus no antibiotics (9%; p=0.779) 8
Evidence Strength
The recommendation against antibiotics for uncomplicated cholelithiasis is supported by:
- High-quality prospective randomized trials showing no benefit 2
- 2022 Surgical Infection Society Guidelines with strong recommendations against routine use 1
- Microbiological evidence that bile is sterile in 85% of uncomplicated cases 3
- Large retrospective studies confirming lack of benefit even with spillage 8