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.[1][2][3][4][5]
  • Antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy.[6]

Acute cholecystitis

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:[7]

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.[8][9][10]
    • 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.

References

  1. Yoshida M, Takada T, Kawarada Y, Tanaka A, Nimura Y, Gomi H, Hirota M, Miura F, Wada K, Mayumi T, Solomkin JS, Strasberg S, Pitt HA, Belghiti J, de Santibanes E, Fan ST, Chen MF, Belli G, Hilvano SC, Kim SW, Ker CG (2007). "Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. 14 (1): 83–90. PMC 2784497Freely accessible. PMID 17252301. doi:10.1007/s00534-006-1160-y. 
  2. "Cholecystitis - ScienceDirect". 
  3. Yokoe M, Takada T, Strasberg SM, Solomkin JS, Mayumi T, Gomi H, Pitt HA, Garden OJ, Kiriyama S, Hata J, Gabata T, Yoshida M, Miura F, Okamoto K, Tsuyuguchi T, Itoi T, Yamashita Y, Dervenis C, Chan AC, Lau WY, Supe AN, Belli G, Hilvano SC, Liau KH, Kim MH, Kim SW, Ker CG (2013). "TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos)". J Hepatobiliary Pancreat Sci. 20 (1): 35–46. PMID 23340953. doi:10.1007/s00534-012-0568-9. 
  4. Bornscheuer T, Schmiedel S (2014). "Calculated Antibiosis of Acute Cholangitis and Cholecystitis". Viszeralmedizin. 30 (5): 297–302. PMC 4571718Freely accessible. PMID 26535043. doi:10.1159/000368335. 
  5. Loozen CS, Oor JE, van Ramshorst B, van Santvoort HC, Boerma D (2017). "Conservative treatment of acute cholecystitis: a systematic review and pooled analysis". Surg Endosc. 31 (2): 504–515. PMID 27317033. doi:10.1007/s00464-016-5011-x. 
  6. "Systematic review of antibiotic treatment for acute calculous cholecystitis - van Dijk - 2016 - BJS - Wiley Online Library". 
  7. Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin. Infect. Dis. 50 (2): 133–64. PMID 20034345. doi:10.1086/649554. 
  8. Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O'Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Surg Infect (Larchmt). 11 (1): 79–109. PMID 20163262. doi:10.1089/sur.2009.9930. 
  9. Hoffmann C, Zak M, Avery L, Brown J (2016). "Treatment Modalities and Antimicrobial Stewardship Initiatives in the Management of Intra-Abdominal Infections". Antibiotics (Basel). 5 (1). PMC 4810413Freely accessible. PMID 27025526. doi:10.3390/antibiotics5010011. 
  10. Gomi H, Solomkin JS, Takada T, Strasberg SM, Pitt HA, Yoshida M, Kusachi S, Mayumi T, Miura F, Kiriyama S, Yokoe M, Kimura Y, Higuchi R, Windsor JA, Dervenis C, Liau KH, Kim MH (2013). "TG13 antimicrobial therapy for acute cholangitis and cholecystitis". J Hepatobiliary Pancreat Sci. 20 (1): 60–70. PMID 23340954. doi:10.1007/s00534-012-0572-0. 

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