## Antibiotic Management of Acute Cholecystitis ### Microbiology & Rationale Acute cholecystitis involves mixed aerobic and anaerobic bacteria (E. coli, Klebsiella, Bacteroides, Clostridium). Empiric coverage must target both gram-negative aerobes and anaerobes. **Key Point:** Ceftriaxone (3rd-generation cephalosporin) + metronidazole is the gold-standard empiric regimen for acute cholecystitis in haemodynamically stable patients without peritonitis. ### Why This Combination? | Agent | Coverage | Role | |-------|----------|------| | Ceftriaxone | Gram-negative aerobes (E. coli, Klebsiella), some gram-positives | Primary aerobic coverage | | Metronidazole | Anaerobes (Bacteroides, Clostridium) | Anaerobic coverage | **High-Yield:** This combination provides broad-spectrum coverage without the nephrotoxicity risk of aminoglycosides and is suitable for biliary penetration. ### Duration & Escalation - Continue antibiotics for 7–10 days if managed conservatively (percutaneous drainage or delayed cholecystectomy). - Escalate to carbapenems (meropenem) or add aminoglycosides only if septic or immunocompromised. **Clinical Pearl:** In elderly or diabetic patients with emphysematous cholecystitis or gangrenous changes, consider early imaging (CT) and urgent surgical intervention rather than prolonged antibiotic monotherapy. ### Surgical Timing - Early laparoscopic cholecystectomy (within 72 hours) is preferred in fit patients. - Percutaneous cholecystostomy + delayed cholecystectomy in high-risk or unfit patients.
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