Cholecystitis / Cholangitis

Mild Severity

  • Symptoms mirror minor biliary colic
  • DOES NOT require antimicrobial therapy

Moderate Severity or Risk

Severity criteria (one or more):

  • Steady and severe pain (RUQ or epigastrium)
  • Fever
  • Leukocytosis

Additional Points:

  • Prior antibiotic use in the last 3 months is a significant consideration in empiric therapy selection. A class effect needs to be considered.
  • Anaerobic coverage (with metronidazole) is acknowledged to be controversial for moderate severity cholecystitis /cholangitis.
  • Shorter durations of therapy should be encouraged when patients exhibit significant clinical improvement.
  • Blood cultures recommended (particularly for cholangitis).

Usual Pathogens
Enterobacteriaceae
Anaerobes
Enterococcus spp. (not routinely covered for moderately severe infections)

Recommended Empiric Therapy (4 – 7 days)

Cefazolin 1 g IV q8h + Metronidazole 500 mg IV/PO q8h

Severe pen-allergy or cephalosporin allergy (e.g. anaphylaxis, angioedemia):

Ciprofloxacin 400 mg IV / 500 mg PO q12h + Metronidazole 500 mg IV/PO q8h

Severe or High Risk

Severity Criteria
Septic presentation (includes the following):

  • Systemic inflammatory response syndrome (SIRS): hypothermia or fever; tachycardia; tachypnea or hypocapnia (arterial CO2 less than 32 mm Hg); and leukopenia or leukocytosis.
  • Evidence of organ dysfunction, hypotension (low blood pressure), or hypoperfusion to 1 or more organs.
  • Arterial hypotension or hypoperfusion is responsive to adequate fluid resuscitation. If unresponsive see empiric therapy for SEPTIC SHOCK below.

High Risk criteria (one or more):

  • Healthcare-associated infection.
  • Recent ERCP or stent in place.
  • Patient has bilio-enteric anastomosis, e.g. post pancreaticoduodenectomy (Whipple’s procedure).
  • Liver transplant.

Those requiring enterococcal coverage such as:

  • Antimicrobial exposure in the last 90 days to cephalosporins and other broad-spectrum regimens selecting for enterococci.
  • With valvular heart disease or intravascular prosthetic devices.
  • Severe immunosuppression (e.g. solid organ transplant, or high-dose steroids).

Additional Points:

  • Prior antibiotic use in the last 3 months is a significant consideration in empiric therapy selection. Use of an agent from a different class of antibiotic is highly recommended.
  • Blood cultures recommended (high risk of bacteremia).
  • Drainage of obstructed biliary tree is essential for therapy of cholangitis.
  • The severely ill patient with cholangitis may take slightly longer to resolve compared to the surgically treated cholecystitis patient.

Usual Pathogens
Enterobacteriaceae
Anaerobes
Enterococcus spp.

Recommended Empiric Therapy (7 – 10 days)
Duration should be guided by intraoperative findings and clinical response and should be no more than 7 days in most cases.

Piperacillin-tazobactam 3.375 g IV q6h

Penicillin allergic (clear history):

Ciprofloxacin 400 mg IV q12h + Metronidazole 500 mg IV q8h + Vancomycin 15 mg/kg (round to nearest 250 mg) IV q12h.
Adjust vancomycin interval based on GFR.

Septic Shock

Criteria (includes all of the following):

  • Systemic inflammatory response syndrome (SIRS) which includes hypothermia or fever; tachycardia; tachypnea or hypocapnia (arterial CO2 less than 32 mm Hg); and leukopenia or leukocytosis.
  • Evidence of organ dysfunction, hypotension (low blood pressure), or hypoperfusion to 1 or more organs.
  • Arterial hypotension or hypoperfusion (despite adequate fluid resuscitation) resulting in the need for vasopressors.

Additional Points:

  • Implement antibiotics immediately. Broad-spectrum agents should be infused first.
  • Consult intensive care.

Recommended Empiric Therapy (7 – 10 days)
Duration should be guided by intra-operative findings and clinical response and should be no more than 7 days in most cases.

Imipenem 500 mg IV q6h + Vancomycin 20 mg/kg (round to nearest 250 mg) x 1 dose, then 15 mg/kg (round to nearest 250 mg) IV q12h.
Adjust vancomycin interval based on GFR.

Severe pen-allergy or cephalosporin allergy (e.g. anaphylaxis, angioedemia):

Ciprofloxacin 400 mg IV q12h + Gentamicin 2 mg/kg IV x STAT (further dosing to be reassessed by the attending intensivist) + Metronidazole 500 mg IV q8h + Vancomycin 20 mg/kg (round to nearest 250 mg) x 1 dose, then 15 mg/kg (round to nearest 250 mg) IV q12h.
Adjust interval based on GFR.