Acute cholecystitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2]

Overview

The mainstay of treatment for acute cholecystitis (calculous and acalculous) is surgery. Pharmacologic medical therapy is recommended for cases of acute cholecystitis in which surgery is delayed. Empiric pharmacologic medical therapies for acute cholecystitis include either amoxicillin-clavulanic acid, cefoxitin, cefotaxime, or ceftriaxone with metronidazole, and ciprofloxacin or levofloxacin with metronidazole. The duration of medical therapy after the cholecystectomy depends on the severity of the disease.

Medical Therapy

• Pharmacologic medical therapy is recommended for cases of acute cholecystitis (calculous and acalculous) in which surgery is delayed and in complicated cases.
  • Empiric pharmacologic medical therapies for acute cholecystitis include either amoxicillin-clavulanic acid, cefoxitin, cefotaxime, or ceftriaxone with metronidazole, and ciprofloxacin or levofloxacin with metronidazole.
  • Empirically administered antimicrobial drugs should be changed for more appropriate agents, according to the identified causative microorganisms and their susceptibility testing results.
• Antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy.

Acute cholecystitis

• 1 Stage 1 - Mild (grade I) acute cholecystitis
  • 1.1 Adult
    • Oral regimens:
      • Preferred regimen (1): Levofloxacin
      • Preferred regimen (2): Ciprofloxacin
      • Preferred regimen (3): Cefotiam
      • Preferred regimen (4): Cefazolin
      • Alternative regimen (1): Ampicillin/sulbactam

• 2 Stage 2 - Moderate (grade II) and severe (grade III) acute cholecystitis
  • 2.1 Adult
    • Preferred regimen (1): Piperacillin/tazobactam 3.375 or 4.5 g IV q6h
    • Preferred regimen (2): Ampicillin/sulbactam 3 g IV q6h
    • Preferred regimen (3): Ceftriaxone 1 g IV q24h or 2 g IV q12h for CNS infections
    • Alternative regimen (3): Levofloxacin plus metronidazole 500 or 750 mg IV q24h plus 500 mg IV q8h
    • Alternative regimen (3): Ciprofloxacin plus metronidazole 400mg IV q24h plus 500 mg IV q8h
    • Alternative regimen (3): Meropenem 1mg IV q6h
    • Alternative regimen (3): Imipenem 500mg IV q6h

Add metronidazole to the preferred regimen (1), (2), and (3) if anaerobic bacteria are suspected.

Recommendations of Infectious Diseases Society of America

Infectious Diseases Society of America recommends the following antibiotic regimens for patients with acute cholecystitis: Acute cholecystitis Drugs recommended Community-acquired acute cholecystitis of mild-to-moderate severity Cefazolin, cefuroxime, or ceftriaxone Community-acquired acute cholecystitis of severe physiologic disturbance, advanced age, or immunocompromised state Imipenem-cilastatin, meropenem, doripenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime, each in combination with metronidazole^ Acute cholangitis following bilio-enteric anastomosis of any severity Imipenem-cilastatin, meropenem, doripenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime, each in combination with metronidazole^ Health care–associated biliary infection of any severity Imipenem-cilastatin, meropenem, doripenem, piperacillin-tazobactam, ciprofloxacin, levofloxacin, or cefepime, each in combination with metronidazole, vancomycin added to each regimen^ ^ Because of increasing resistance of Escherichia coli to fluoroquinolones, local population susceptibility profiles and, if available, isolate susceptibility should be reviewed. Adopted from Journal of Hepato-Biliary-Pancreatic Sciences

Duration of therapy

• The duration of the antibiotic in acute cholecystitis depends on the severity of the disease.
  • Antibiotic therapy should be discontinued within 24 hours of cholecystectomy for mild cholecystitis unless there is evidence of infection extending outside of the gallbladder.
  • Antibiotic therapy is discontinued within 4-7 days for moderate-severe cholecystitis.
  • In the cases of bacteremia with gram-positive bacteria known to cause infective endocarditis (eg, Enterococcus and Streptococcus), consider continuing antibiotics for 14 days.