Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Agents used in patients with cholecystitis include antiemetics, analgesics, and antibiotics.
Antiemetics
Class Summary
Patients with cholecystitis frequently experience nausea and vomiting. Antiemetics can help make the patient more comfortable and can prevent fluid and electrolyte abnormalities.
Promethazine (Phenergan, Promethegan, Phenadoz)
Promethazine is used for symptomatic treatment of nausea in vestibular dysfunction. It is an antidopaminergic agent effective in treating emesis. It blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system.
Prochlorperazine (Compazine)
Prochlorperazine may relieve nausea and vomiting by blocking the postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing the reticular activating system. In addition to the antiemetic effects, it has the advantage of augmenting hypoxic ventilatory response, acting as a respiratory stimulant at high altitude.
Analgesics
Class Summary
Pain is a prominent feature of cholecystitis. The classic teaching is that morphine is not the agent of choice because of the possibility of increasing tone at the sphincter of Oddi. Meperidine has been shown to provide adequate analgesia without affecting the sphincter of Oddi and, therefore, is the drug of choice.
Meperidine (Demerol)
Meperidine is the drug of choice for pain control. It is an analgesic with multiple actions similar to those of morphine. It may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Hydrocodone and acetaminophen (Vicodin, Lortab 5/500, Lorcet-HD)
This drug combination is indicated for moderate to severe pain. Each tab/cap contains 5 mg hydrocodone and 500 mg acetaminophen.
Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)
This drug combination is indicated for relief of moderate to severe pain. Each tab/cap contains 5 mg oxycodone and 325 mg acetaminophen.
Antibiotics
Class Summary
Treatment of cholecystitis with antibiotics should provide coverage against the most common organisms, including Escherichia coli and Bacteroides fragilis, as well as Klebsiella,Pseudomonas, and Enterococcus species. Sanford Guide recommendations for the treatment of cholecystitis include ampicillin/sulbactam or piperacillin/tazobactam for non–life-threatening cases of cholecystitis. In life-threatening cases, Sanford recommends imipenem/cilastatin or meropenem. Alternatives include metronidazole plus a third-generation cephalosporin, ciprofloxacin, or aztreonam.
Ciprofloxacin (Cipro)
Ciprofloxacin is a fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have a broad activity against gram-positive and gram-negative aerobic organisms but no activity against anaerobes. Continue treatment for at least 2 days (7-14 days is typical) after signs and symptoms have disappeared.
Meropenem (Merrem)
Meropenem is a bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. It is effective against most gram-positive and gram-negative bacteria. It has slightly increased activity against gram-negatives and slightly decreased activity against staphylococci and streptococci compared to imipenem.
Imipenem and cilastatin (Primaxin)
This combination is used to treat multiple-organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of potential for toxicity.
Piperacillin and tazobactam (Zosyn)
This combination is an antipseudomonal penicillin plus a beta-lactamase inhibitor. It inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active multiplication.
Ampicillin and sulbactam (Unasyn)
This drug combination is a beta-lactamase inhibitor with ampicillin. It covers epidermal and enteric flora and anaerobes. It is not ideal for nosocomial pathogens.
Metronidazole (Flagyl)
Metronidazole is an imidazole ring-based antibiotic that is active against various anaerobic bacteria and protozoa. It is used in combination with other antimicrobial agents (except in Clostridium difficile enterocolitis).
Levofloxacin (Levaquin)
Levofloxacin is a fluoroquinolone that is used for pseudomonal infections and infections due to multidrug-resistant gram-negative organisms. Prophylactic antibiotic coverage with levofloxacin (Levaquin, 500 mg PO qd) and metronidazole (500 mg PO bid) provides coverage against the most common organisms in cases of uncomplicated cholecystitis.
Aztreonam (Azactam)
Aztreonam is a monobactam, not a beta-lactam, antibiotic that inhibits cell wall synthesis during bacterial growth. It is active against gram-negative bacilli but has very limited gram-positive activity and is not useful for anaerobes. It lacks cross-sensitivity with beta-lactam antibiotics. Aztreonam may be used in patients allergic to penicillins or cephalosporins and is an alternative to life-threatening cases of cholecystitis.
Ceftriaxone (Rocephin)
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity; it has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Its bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. It exerts an antimicrobial effect by interfering with the synthesis of peptidoglycan, a major structural component of bacterial cell walls. Bacteria eventually lyse as a result of the ongoing activity of cell wall autolytic enzymes, while cell wall assembly is arrested.
Cefotaxime (Claforan)
Cefotaxime is a third-generation cephalosporin with a broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
Ceftazidime (Fortaz)
Ceftazidime is a third-generation cephalosporin with broad-spectrum, gram-negative activity, including against pseudomonas; it has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. It arrests bacterial growth by binding to one or more penicillin-binding proteins, which, in turn, inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall synthesis, thus inhibiting cell wall biosynthesis.
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Acute Cholecystitis. Normal finding on hepatoiminodiacetic acid (HIDA) scan.
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Acute Cholecystitis. Abnormal finding on hepatoiminodiacetic acid (HIDA) scan.
