eMedicine Specialties > Gastroenterology > Biliary
Empyema, Gallbladder: Treatment & Medication
Updated: Jun 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Intravenous antibiotic therapy is an adjunct to urgent decompression and/or resection of the gallbladder when empyema is likely. The choice of antibiotic is based on the organisms presumed to be involved (see Causes). Early in the course of the disease, good results are achieved with the adjuvant administration of ampicillin or a first- or second-generation cephalosporin. In more advanced cases associated with perforation and/or generalized sepsis, triple antibiotic therapy that includes an aminoglycoside (usually gentamicin), ampicillin or a cephalosporin, and metronidazole (anaerobic coverage) is advised.
Antibiotic coverage is modified by culture results and the bacterial resistance encountered in the local hospital setting.
Urgent decompression is the goal of therapy for empyema of the gallbladder. In patients who are hemodynamically unstable or in individuals in whom surgery is contraindicated because of significant comorbid conditions, transhepatic drainage of the gallbladder under radiologic guidance may serve as a temporizing or final procedure. Though rapid and marked improvement in the patient's condition usually follows, complete resolution without further septic complication (mandating further intervention) is unpredictable.
Surgical Care
Surgical decompression and resection of the affected gallbladder is the criterion standard of therapy. An advanced laparoscopic surgeon may treat empyema of the gallbladder (without significant gangrenous changes or perforation) with a laparoscopic procedure. Initial decompression may be accomplished under radiographic guidance immediately before the procedure or via intraoperative, laparoscopically guided needle drainage, which allows for more facile manipulation of the gallbladder during the cholecystectomy portion of the procedure.
The conversion-to-open and complication rates reported in the literature for laparoscopic treatment of empyema vary widely. However, they are all significantly higher than the comparative rates reported in the same studies for laparoscopic treatment of uncomplicated acute cholecystitis. Laparoscopic subtotal cholecystectomy is acceptable only if the encountered pericholecystic inflammation is so severe as to preclude safe dissection via either a laparoscopic procedure or an open procedure.1
Importantly, the complications are related to the advanced disease process and not to the approach. In skilled hands, no increase is observed in the incidence of laparoscopic surgical misadventure with empyema of the gallbladder. Thus, despite the higher incidence of conversion to an open procedure (40-80%), it is quite reasonable to initially proceed with a laparoscopic procedure.
Consultations
When empyema of the gallbladder is considered, urgent consultation with gastroenterologists and surgeons is essential.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Base selection of antibiotics on blood culture sensitivity whenever feasible. Indicated as an adjunct to decompression/resection of the gallbladder with empyema.
Gentamicin (Garamycin)
Aminoglycoside antibiotic for gram-negative coverage bacteria, including Pseudomonas species. Synergistic with beta-lactamase against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least a trough level drawn on the third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.
Adult
Loading dose and maintenance dose: 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, q8h
Serious life-threatening infections and normal renal function: 3 mg/kg/dose IV q8h
Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion
Pediatric
Not established
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non-dialysis dependent renal insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment
Ampicillin (Omnipen, Polycillin)
Indicated as single-agent therapy in early empyema of the gallbladder. Bactericidal activity against susceptible organisms. Dosing depends on severity of infection.
Adult
1-2 g IV q4-6h; not to exceed 14 g/d
Pediatric
100-200 mg/kg/d IV divided q4-6h; not to exceed 2-3 g/d
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash, and differentiate from hypersensitivity reaction
Cefazolin (Ancef, Kefzol)
Indicated as single-agent therapy in early empyema of the gallbladder. First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, thus inhibiting bacterial growth. Dosing depends on severity of infection.
Adult
1-2 g IV/IM q6-12h; not to exceed 12 g/d
Pediatric
25-100 mg/kg/d IV divided q8h
Probenecid prolongs effects; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test results for glucose
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged or repeated use
Metronidazole (Flagyl)
Indicated in severe infection in combination with aminoglycoside and ampicillin. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents.
Adult
Loading dose: 15 mg/kg or 1 g IV over 1 h for 70-kg patient
Maintenance dose: 6 h following IV loading dose, infuse 7.5 mg/kg or 500 mg IV q6-8h over 1 h for 70-kg patient; not to exceed 4 g/d
Pediatric
30 mg/kg/d IV divided q6h; not to exceed 4 g/d
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
More on Empyema, Gallbladder |
| Overview: Empyema, Gallbladder |
| Differential Diagnoses & Workup: Empyema, Gallbladder |
 Treatment & Medication: Empyema, Gallbladder |
| Follow-up: Empyema, Gallbladder |
| References |
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References
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Further Reading
Keywords
empyema of the gallbladder, acute cholecystitis, calculous cholecystitis, acalculous cholecystitis, gangrenous cholecystitis, cholelithiasis, chololithiasis, sepsis, Escherichia coli, E coli, Klebsiella pneumoniae, K pneumoniae, Streptococcus faecalis, S faecalis, Bacteroides, Clostridia
