Table 8 Clinical pathway for patients with acute calculous cholecystitis

 • Clinical signs and symptoms

Diagnosis

 • Abdominal pain in the right upper quadrant of the abdomen. The pain is characteristically worst when palpating the upper right quadrant of the abdomen during deep inspiration by the patient (Murphy’s sign)

 • Fever

 • Absence of vomiting

• Abdominal tenderness (sign of complicated acute cholecystitis)

Laboratory markers

 • Increased white blood cell count

 • Leucocyte shift to left (> 75%)

 • C-reactive protein

Imaging

 • US

 • CT

 • MRI

Uncomplicated Colecystitis

Treatment

 • Early (within 7-10 days) laparoscopic/open cholecystectomy (Early treatment). Post-operative antibiotics are unnecessary if source control is adequate.

 • Antibiotic therapy and planned delayed laparoscopic/open cholecystectomy (delayed treatment).

Complicated cholecystitis

 • Laparoscopic cholecystectomy, with open cholecystectomy as an alternative, and antibiotic therapy for 4 days

 • Cholecystostomy may be an option for acute cholecystitis in critically ill with multiple comorbidities and unfit for surgery patients who do not show clinical improvement after antibiotic therapy for 3-5 days. However current evidence shows that cholecystostomy is inferior to cholecystectomy in terms of major complications for patients with an APACHE score of 7–14 in terms of major complications.

Amoxicillin/clavulanate 2.2 g every 8 h +/− gentamicin 5–7 mg/Kg every 24 h

Antibiotic therapy

Avoid Amoxicillin/clavulanate if local Enterobacteriaceae resistances > 20%.

Piperacillin/tazobactam 6 g/0.75 g LD then 4 g/0.5 g every 6 h or 16 g/2 g by continuous infusion +/− gentamicin 5–7 mg/Kg every 24 h (in critically ill patients)

Ceftriaxone 2 g every 24 h + metronidazole 500 mg every 8 h

Cefotaxime 2g every 8 h + metronidazole 500 mg every 8 h

or

In patients with beta-lactam allergy

A fluoroquinolone-based regimen

Ciprofloxacin 400 mg every 8/12 h + metronidazole 500 mg every 8 h

or

An aminoglycoside-based regimen

Amikacin 15-20 mg/kg every 24 h + metronidazole 500 mg every 8 h

or

In patients at high risk for infection with community-acquired ESBL-producing

Enterobacteriaceae

One of the following antibiotics

Tigecycline 100 mg LD, then 50 mg every 12 h (carbapenem-sparing strategy)

Ertapenem 1 g every 24 h

Meropenem 1 g every 8 h (only in patients with septic shock)

Doripenem 500 mg every 8 h (only in patients with septic shock)

Imipenem/cilastatin 500 mg every 6 h (only in patients with septic shock)

In patients at high risk for infection from enterococci including immunocompromised patients or patients with recent antibiotic exposure, consider the use of ampicillin 2 g every 6 h if patients are not being treated with piperacillin/tazobactam or imipenem/cilastatin (active against ampicillin-susceptible enterococci) or tigecycline