Specific Organisms and Therapeutic Regimens
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, 9]
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]
Enterococci
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
Bacteroides spp.
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
Enterobacteriaceae spp.
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
-
Moxifloxacin 400 mg IV q24h [10] 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. [11]
ESBL-producing Enterobacteriaceae
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 )
Pseudomonas aeruginosa
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
Salmonella typhi
See below.
-
Ciprofloxacin 400 mg IV q12h [12]
Perioperative considerations
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]
