Empirical antibiotic therapy for acute acalculous cholecystitis

For the treatment of patients with acute acalculous 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 undergoing surgery.

The rationale for antibiotic choice for intra-abdominal infections, including acute acalculous cholecystitis, is described here.

For empirical therapy of acute acalculous cholecystitis in children, seek expert advice.

For empirical therapy of acute acalculous cholecystitis in adults without sepsis or septic shock, as a 3-drug regimen, use:

To avoid the need to switch between intravenous antibiotics at 72 hours, piperacillin+tazobactam 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. Piperacillin+tazobactam is also used if gentamicin or tobramycin is contraindicated. For empirical therapy of acute acalculous cholecystitis in adults without sepsis or septic shock, use:

For adults with hypersensitivity to penicillins, as a 2-drug regimen, use:

If the clindamycin-containing regimen is used and prompt source control (cholecystectomy or cholecystotomy) is unlikely to occur (eg within 24 hours), consider adding metronidazole because there is increasing resistance to clindamycin in gram-negative anaerobes (especially Bacteroides species); in adults, add: