Empirical antibiotic therapy for acute calculous cholecystitis
For the treatment of patients with acute calculous cholecystitis who have sepsis or septic shock, see Sepsis and septic shock from a biliary or gastrointestinal tract source. For definitions of sepsis and septic shock, see Identifying sepsis or septic shock.
The empirical regimens in this topic may not be appropriate for patients with risk factors for infection with multidrug-resistant Enterobacterales. These patients may also develop infection with other resistant pathogens (eg vancomycin-resistant enterococci) and Candida species. Seek expert advice to guide antimicrobial choice.
Adjustments to empirical therapy may be required for patients having cholecystectomy.
The rationale for antibiotic choice for intra-abdominal infections, including acute calculous cholecystitis, is described here.
For empirical therapy of acute calculous cholecystitis in children, seek expert advice.
For empirical therapy of acute calculous cholecystitis in adults without sepsis or septic shock, as a 2-drug regimen, use:
1gentamicin intravenously; see Gentamicin initial dose calculator for adults for initial dose. See Principles of aminoglycoside use for prescribing considerations and subsequent dosing. See advice on modification and duration of therapygentamicin gentamicin gentamicin
OR
1tobramycin intravenously; see Tobramycin initial dose calculator for adults for initial dose. See Principles of aminoglycoside use for prescribing considerations and subsequent dosing. See advice on modification and duration of therapy tobramycin tobramycin tobramycin
PLUS with either of the above drugs, either of the following
1amoxicillin 2 g intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin dosage adjustment. See advice on modification and duration of therapy amoxicillin amoxicillin amoxicillin
OR
1ampicillin 2 g intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see ampicillin dosage adjustment. See advice on modification and duration of therapy. ampicillin ampicillin ampicillin
To avoid the need to switch between intravenous antibiotics at 72 hours, a non-aminoglycoside–containing regimen may be used if it is suspected that intravenous therapy will continue for at least 72 hours. If the likely duration of intravenous therapy is not known, start with the aminoglycoside-containing regimen; do not delay antibiotic administration to make this determination. Non-aminoglycoside–containing regimens are also used if gentamicin or tobramycin is contraindicated. For empirical therapy of acute calculous cholecystitis in adults without sepsis or septic shock, use:
1ceftriaxone 2 g intravenously, daily. See advice on modification and duration of therapy ceftriaxone ceftriaxone ceftriaxone
OR
2amoxicillin+clavulanate 2+0.2 g intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment. See advice on modification and duration of therapy amoxicillin + clavulanate amoxicillin+clavulanate amoxicillin+clavulanate
OR
2amoxicillin+clavulanate 1+0.2 g intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment. See advice on modification and duration of therapy amoxicillin + clavulanate amoxicillin+clavulanate amoxicillin+clavulanate.
For adults who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use ceftriaxone as above.
For adults who have had a severe immediate1 hypersensitivity reaction to a penicillin, ceftriaxone (at the dosage above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For adults who have had a severe immediate1 hypersensitivity reaction to a penicillin in whom ceftriaxone is not used, or for adults who have had a severe delayed2 hypersensitivity reaction to a penicillin, gentamicin or tobramycin as a single drug is usually adequate (see dosages above).