Cholecystitis Organism-Specific Therapy 

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Organism-specific therapeutic regimens for cholecystitis are provided below, including those for enterococci, Bacteroides species (spp), and Enterobacteriaceae spp infections, as well as for perisurgical considerations. ^{[1, 2, 3, 4, 5, 6, 7, 8]}

Factors to be considered in the selection of antibiotics for cholecystitis are targeted organisms and the pharmacokinetics and pharmacodynamics of the drugs. The local antibiogram, as well as the patient’s history of antimicrobial usage, renal and hepatic function, history of allergies and other adverse events are also important factors that affect response to antibiotics. ^[7]

See the following:

Ampicillin 2 g IV q4h

Vancomycin 1 g IV q12h

Vancomycin-resistant enterococci (VRE)

Daptomycin 6 mg/kg IV q24h for 2-4 weeks or

Linezolid 600 mg PO/IV q12h for 14-28 days

Clindamycin resistance among Bacteroides species is significant; therefore, the use of clindamycin is no longer universally recommended. Local antibiotic sensitivity patterns will guide clinicians regarding the efficacy and utility of clindamycin. ^[7]

Clindamycin 600 mg IV q8h or

Metronidazole 500 mg IV q8h or

Ampicillin-sulbactam 3 g IV q6h or

Piperacillin-tazobactam 3.375 g IV q6h 

Note the following regimens:

Piperacillin-tazobactam 3.375 g IV q6h or

Ciprofloxacin 400 mg IV q12h plus  metronidazole 500 mg IV q8h or

Levofloxacin 750 mg IV daily plus  metronidazole 500 mg IV q8h or

Imipenem-cilastatin 250-500 mg IV q6-8h or

Ertapenem 1 g IV daily or

Meropenem 0.5-1 g IV q8h or

Doripenem 500 mg IV q8h

The use of ampicillin/sulbactam as monotherapy is no longer recommended because of high rates of resistance to this agent among community-acquired Escherichia coli. ^[10]  

See the following regimens:

Imipenem-cilastatin 250-500 mg IV q6-8h or

Ertapenem 1 g IV daily or

Meropenem 0.5-1 g IV q8h or

Doripenem 500 mg IV q8h or

Piperacillin-tazobactam 3.375 g IV q6h or

Aminoglycosides (Amikacin 750 mg iv q24h )

See the following regimens:

Imipenem-cilastatin 250-500 mg IV q6-8h or

Meropenem 0.5-1 g IV or

Doripenem 500 mg IV or

Piperacillin-tazobactam 3.375 g IV q6h plus metronidazole 500 mg IV q8h 

See below.

Prophylaxis with cefazolin 1-2 g IV within 60 minutes before surgical incision is indicated for routine cholecystectomy in high-risk patients, as well as in high-risk patients in general. The same recommendations may be applied for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP).

Antibiotics are generally not recommended immediately following surgery, unless there is clinical and laboratory evidence of infection.

When cholecystectomy is performed, antibiotics can be stopped within 24 hours. However, there is an indication to continue antibiotics even after cholecystectomy in grade II and grade III acute cholecystitis. ^[7]

Claesson B, Holmlund D, Matzsch T. Biliary microflora in acute cholecystitis and the clinical implications. Acta Chir Scand. 1984. 150(3):229-37. [Medline].

Teixeira JP, Malheiro L, Pontinha N, et al. Infectious factors in acute acalculous cholecystitis. Hepatogastroenterology. 2002 Nov-Dec. 49(48):1484-6. [Medline].

Babb RR. Acute acalculous cholecystitis. A review. J Clin Gastroenterol. 1992 Oct. 15(3):238-41. [Medline].

Barakos JA, Ralls PW, Lapin SA, et al. Cholelithiasis: evaluation with CT. Radiology. 1987 Feb. 162(2):415-8. [Medline].

Hakansson K, Leander P, Ekberg O, Hakansson HO. MR imaging in clinically suspected acute cholecystitis. A comparison with ultrasonography. Acta Radiol. 2000 Jul. 41(4):322-8. [Medline].

Solomkin JS, Mazuski JE, Bradley JS, et al. 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). 2010 Feb. 11(1):79-109. [Medline].

Takada T, Strasberg SM, Solomkin JS, et al, for the Tokyo Guidelines Revision Committee. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013 Jan. 20(1):1-7. [Medline]. [Full Text].

Gomi H, Solomkin JS, Takada T, et al, for the Tokyo Guideline Revision Committee. TG13 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013 Jan. 20(1):60-70. [Medline]. [Full Text].

Solomkin J, Zhao YP, Ma EL, Chen MJ, Hampel B, for the DRAGON Study Team. Moxifloxacin is non-inferior to combination therapy with ceftriaxone plus metronidazole in patients with community-origin complicated intra-abdominal infections. Int J Antimicrob Agents. 2009 Nov. 34(5):439-45. [Medline].

Solomkin JS, Mazuski JE, Bradley JS, et al. 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. 2010 Jan 15. 50(2):133-64. [Medline].

Ballal M, Jyothi KN, Antony B, Arun C, Prabhu T, Shivananda PG. Bacteriological spectrum of cholecystitis and its antibiogram. Indian J Med Microbiol. 2001 Oct-Dec. 19(4):212-4. [Medline].

Ansaloni L, Pisano M, Coccolini F, et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016. 11:25. [Medline].

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

A R Pranavi, MBBS Resident Physician, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Disclosure: Nothing to disclose.

Mohsina Subair, MBBS, MS (GenSurg), MRCS(Edin) Former Senior Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India

Mohsina Subair, MBBS, MS (GenSurg), MRCS(Edin) is a member of the following medical societies: Association of Surgeons of India, Royal College of Surgeons of Edinburgh, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, Royal College of Physicians and Surgeons of the United States, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Radiologists, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Cholecystitis Organism-Specific Therapy 

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