Acute cholecystitis medical therapy: Difference between revisions

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{{Acute cholecystitis}}
{{Acute cholecystitis}}
{{CMG}}; {{AE}} {{MMF}}
==Overview==
==Overview==


The mainstay of treatment for acute cholecystitis is surgery. Pharmacologic medical therapy is recommended for patients with acute cholecystitis in which surgery is delayed.
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==
==Medical Therapy==
*Pharmacologic medical therapy is recommended for patients with acute cholecystitis in which surgery is delayed and in complicated cases.
*Pharmacologic medical therapy is recommended for cases of acute cholecystitis (calculous and acalculous) in which surgery is delayed and in complicated cases.<ref name="pmid17252301">{{cite journal |vauthors=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 |title=Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines |journal=J Hepatobiliary Pancreat Surg |volume=14 |issue=1 |pages=83–90 |year=2007 |pmid=17252301 |pmc=2784497 |doi=10.1007/s00534-006-1160-y |url=}}</ref><ref name="urlCholecystitis - ScienceDirect">{{cite web |url=http://www.sciencedirect.com/science/article/pii/S0039610914000061?via%3Dihub#bib9 |title=Cholecystitis - ScienceDirect |format= |work= |accessdate=}}</ref><ref name="pmid23340953">{{cite journal |vauthors=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 |title=TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos) |journal=J Hepatobiliary Pancreat Sci |volume=20 |issue=1 |pages=35–46 |year=2013 |pmid=23340953 |doi=10.1007/s00534-012-0568-9 |url=}}</ref><ref name="pmid26535043">{{cite journal |vauthors=Bornscheuer T, Schmiedel S |title=Calculated Antibiosis of Acute Cholangitis and Cholecystitis |journal=Viszeralmedizin |volume=30 |issue=5 |pages=297–302 |year=2014 |pmid=26535043 |pmc=4571718 |doi=10.1159/000368335 |url=}}</ref><ref name="pmid27317033">{{cite journal |vauthors=Loozen CS, Oor JE, van Ramshorst B, van Santvoort HC, Boerma D |title=Conservative treatment of acute cholecystitis: a systematic review and pooled analysis |journal=Surg Endosc |volume=31 |issue=2 |pages=504–515 |year=2017 |pmid=27317033 |doi=10.1007/s00464-016-5011-x |url=}}</ref>
*Antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy.<ref name="urlSystematic review of antibiotic treatment for acute calculous cholecystitis - van Dijk - 2016 - BJS - Wiley Online Library">{{cite web |url=http://onlinelibrary.wiley.com/doi/10.1002/bjs.10146/abstract |title=Systematic review of antibiotic treatment for acute calculous cholecystitis - van Dijk - 2016 - BJS - Wiley Online Library |format= |work= |accessdate=}}</ref>
**Empiric pharmacologic medical therapies for acute cholecystitis include either [[amoxicillin-clavulanic acid]], [[cefoxitin]], [[cefotaxime]], or [[ceftriaxone]] with [[metronidazole]], and [[ciprofloxacin]] or [[levofloxacin]] with [[metronidazole]].
*Empiric pharmacologic medical therapies for acute cholecystitis include either amoxicillin/clavulanic acid, cefoxitin, cefotaxime, or ceftriaxone with metronidazole, and ciprofloxacin or levofloxacin with metronidazole.
**Empirically administered antimicrobial drugs should be changed for more appropriate agents, according to the identified causative microorganisms and their susceptibility testing results.
*Empirically administered antimicrobial drugs should be changed for more appropriate agents, according to the identified causative microorganisms and their susceptibility testing results.
*Antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for [[cholecystectomy]].<ref name="urlSystematic review of antibiotic treatment for acute calculous cholecystitis - van Dijk - 2016 - BJS - Wiley Online Library">{{cite web |url=http://onlinelibrary.wiley.com/doi/10.1002/bjs.10146/abstract |title=Systematic review of antibiotic treatment for acute calculous cholecystitis - van Dijk - 2016 - BJS - Wiley Online Library |format= |work= |accessdate=}}</ref>


===Disease Name===
===Acute cholecystitis===


* '''1 Stage 1 - Mild (grade I) acute cholecystitis'''
* '''1 Stage 1 - Mild (grade I) acute cholecystitis'''
** 1.1 '''Adult'''
** 1.1 '''Adult'''
*** Preferred regimen (1): [[Ampicillin/sulbactam]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
***Oral regimens:
*** Preferred regimen (2): [[Ciprofloxacin]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (1): [[Levofloxacin]]  
*** Preferred regimen (3): [[Levofloxacin]] 500 mg q12h for 14-21 days
**** Preferred regimen (2): [[Ciprofloxacin]]  
*** Alternative regimen (1): [[Cefazolin]] 500 mg PO q6h for 7–10 days 
**** Preferred regimen (3): [[Cefotiam]]
*** Alternative regimen (2): [[Cefotiam]] 500 mg PO q12h for 14–21 days
**** Preferred regimen (4): [[Cefazolin]]  
*** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
**** Alternative regimen (1): [[Ampicillin/sulbactam]]  


* 2 '''Stage 2 - Moderate (grade II) and severe (grade III) acute cholecystitis'''
* 2 '''Stage 2 - Moderate (grade II) and severe (grade III) acute cholecystitis'''
** 2.1 '''Adult'''
** 2.1 '''Adult'''
***Parenteral regimen
*** Preferred regimen (1): [[Piperacillin/tazobactam]] 3.375 or 4.5 g IV q6h
*** Preferred regimen (1): [[Piperacillin/tazobactam]] 3.375 or 4.5 g IV q6h
*** Alternative regimen (1): [[Ampicillin/sulbactam]] 3 g IV q6h  
*** Preferred regimen (2): [[Ampicillin/sulbactam]] 3 g IV q6h  
*** Alternative regimen (2): [[Ceftriaxone]] 1 g IV q24h or 2 g IV q12h for CNS infections
*** Preferred regimen (3): [[Ceftriaxone]] 1 g IV q24h or 2 g IV q12h for CNS infections
*** Alternative regimen (3): [[Levofloxacin]] plus [[metronidazole]] 500 or 750 mg IV q24h '''plus''' 500 mg IV q8h
*** Alternative regimen (3): [[Ciprofloxacin]] plus [[metronidazole]] 400mg IV q24h '''plus''' 500 mg IV q8h
*** Alternative regimen (3): [[Meropenem]] 1mg IV q6h
*** Alternative regimen (3): [[Imipenem]] 500mg IV q6h
Add [[metronidazole]] to the preferred regimen (1), (2), and (3) if [[Anaerobic organism|anaerobic bacteria]] are suspected.
 
===Recommendations of Infectious Diseases Society of America===
{|
| style="background:#F5F5F5;" + |
Infectious Diseases Society of America recommends the following antibiotic regimens for patients with acute cholecystitis:<ref name="pmid20034345">{{cite journal |vauthors=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 |title=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 |journal=Clin. Infect. Dis. |volume=50 |issue=2 |pages=133–64 |year=2010 |pmid=20034345 |doi=10.1086/649554 |url=}}</ref>
{|
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Acute cholecystitis
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Drugs recommended
 
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Community-acquired acute cholecystitis of mild-to-moderate severity
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Cefazolin]], [[cefuroxime]], or [[ceftriaxone]]
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Community-acquired acute cholecystitis of severe physiologic disturbance, advanced age, or immunocompromised state
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Imipenem-Cilastatin|Imipenem-cilastatin]], [[meropenem]], [[doripenem]], [[piperacillin-tazobactam]], [[ciprofloxacin]], [[levofloxacin]], or [[cefepime]], each in combination with [[metronidazole]]'''^'''
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Acute cholangitis following bilio-enteric anastomosis of any severity
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Imipenem-Cilastatin|Imipenem-cilastatin]], [[meropenem]], [[doripenem]], [[piperacillin-tazobactam]], [[ciprofloxacin]], [[levofloxacin]], or [[cefepime]], each in combination with [[metronidazole]]'''^'''
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Health care–associated biliary infection of any severity
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Imipenem-Cilastatin|Imipenem-cilastatin]], [[meropenem]], [[doripenem]], [[Piperacillin-tazobactam|piperacillin-tazobactam,]] [[ciprofloxacin]], [[levofloxacin]], or [[cefepime]], each in combination with [[metronidazole]], [[vancomycin]] added to each regimen'''^'''
|-
 
|-
|}
<small> '''^''' Because of increasing resistance of Escherichia coli to fluoroquinolones, local population susceptibility profiles and, if available, isolate susceptibility should be reviewed.
 
<small>'''Adopted from [https://doi.org/10.1086/649554 Journal of Hepato-Biliary-Pancreatic Sciences]'''
 
|}
===Duration of therapy===
*The duration of the antibiotic in acute cholecystitis depends on the severity of the disease.<ref name="pmid20163262">{{cite journal |vauthors=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 |title=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 |journal=Surg Infect (Larchmt) |volume=11 |issue=1 |pages=79–109 |year=2010 |pmid=20163262 |doi=10.1089/sur.2009.9930 |url=}}</ref><ref name="pmid27025526">{{cite journal |vauthors=Hoffmann C, Zak M, Avery L, Brown J |title=Treatment Modalities and Antimicrobial Stewardship Initiatives in the Management of Intra-Abdominal Infections |journal=Antibiotics (Basel) |volume=5 |issue=1 |pages= |year=2016 |pmid=27025526 |pmc=4810413 |doi=10.3390/antibiotics5010011 |url=}}</ref><ref name="pmid23340954">{{cite journal |vauthors=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 |title=TG13 antimicrobial therapy for acute cholangitis and cholecystitis |journal=J Hepatobiliary Pancreat Sci |volume=20 |issue=1 |pages=60–70 |year=2013 |pmid=23340954 |doi=10.1007/s00534-012-0572-0 |url=}}</ref>
**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==
==References==
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Latest revision as of 18:43, 27 December 2017

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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. doi:10.1007/s00534-006-1160-y. PMC 2784497. PMID 17252301.
  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. doi:10.1007/s00534-012-0568-9. PMID 23340953.
  4. ↑ Bornscheuer T, Schmiedel S (2014). "Calculated Antibiosis of Acute Cholangitis and Cholecystitis". Viszeralmedizin. 30 (5): 297–302. doi:10.1159/000368335. PMC 4571718. PMID 26535043.
  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. doi:10.1007/s00464-016-5011-x. PMID 27317033.
  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. doi:10.1086/649554. PMID 20034345.
  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. doi:10.1089/sur.2009.9930. PMID 20163262.
  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). doi:10.3390/antibiotics5010011. PMC 4810413. PMID 27025526.
  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. doi:10.1007/s00534-012-0572-0. PMID 23340954.

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