Systematic review of antibiotic treatment for acute calculous cholecystitis

Ultrasound-Guided Interventions in the Biliary System

Ultrasound guidance in biliary interventions has become the standard tool to facilitate percutaneous biliary drainage as well as percutaneous gall bladder drainage. Monitoring of the needle tip whilst penetrating the tissue in real time using ultrasound allows precise manoeuvres and exact targeting without radiation exposure. Without the need for fluoroscopy, ultrasound-guided drainage procedures can be performed bedside as a sometimes life-saving procedure in patients with severe cholangitis/cholecystitis when they are critically ill in intensive care units and cannot be transported to a fluoroscopy suite. This article describes the current data background and guidelines and focuses on specific sonographic aspects of both the procedures of percutaneous biliary drainage and gallbladder drainage.

Usefulness of intraoperative bile culture in patients with acute calculous cholecystitis with previous biliary events: does the postoperative management change?

PURPOSE

The aim of our study was to determine the usefulness of intraoperative gallbladder cultures in the postoperative course in surgically treated patients with acute calculous cholecystitis and previous biliary events (ACC-PBE).

METHODS

Retrospective unicenter study on surgically treated ACC-patients between January 2014 and December 2018. Clinical benefit was defined as a > 20% change in postoperative antibiotic treatment. Secondary endpoints: postoperative morbidity and length-of-stay (LOS) in ACC-PBE patients with positive intraoperative biliary culture (IBC). Statistical significance was defined as p < 0.05.

RESULTS

Out of the initial 711 patients, 203 met the study's inclusion criteria, with 139 of them having IBC results (72 positive, 67 negative). Our analysis revealed no significant difference in the incidence of positive-IBC between patients with ACC-PBE. Among this group, only 6% changed postoperative antibiotic treatment based on IBC results. There were no statistically significant differences in postoperative complications (p: 0.21) or LOS (p: 0.23) in the ACC-PBE group. In multivariate analysis, age > 70 years old (p: 0.00; HR 3.1, 95% IC [1.6-6.4]), prior ERCP (p: 0.02; HR 5.9, 95% IC [1.25-27.5]) and prior antibiotic treatment (p: 0.01; HR 3.6, 95% IC [1.32-9.86]) were identified as independent factors that influenced PBC.

CONCLUSIONS

IBC in operated ACC-PBE do not alter postoperative management. While positive-IBC was associated with age, prior ERCP, and prior antibiotic treatment, these findings did not have a significant impact on postoperative morbidity or LOS.

Value of monocyte distribution width for predicting severe cholecystitis: a retrospective cohort study

OBJECTIVES

Acute cholecystitis is a gallbladder inflammation, and the Tokyo Guidelines 2018 (TG18) can be used to predict its presence and severity with high sensitivity and specificity. However, TG18 grading require the collection of excessive parameters. Monocyte distribution width (MDW) is a parameter used to detect sepsis early. Therefore, we investigated the correlation between MDW and cholecystitis severity.

METHODS

We conducted a retrospective study of patients with cholecystitis admitted to our hospital from November 1, 2020, to August 31, 2021. The primary outcome was severe cholecystitis analyzed as a composite of intensive care unit (ICU) admission and mortality. The secondary outcomes were length of hospital stay, ICU stay, and TG18 grade.

RESULTS

A total of 331 patients with cholecystitis were enrolled in this study. The average MDWs for TG18 grades 1, 2, and 3 were 20.21 ± 3.99, 20.34 ± 3.68, and 25.77 ± 6.61, respectively. For patients with severe cholecystitis, the average MDW was 25.42 ± 6.83. Using the Youden J statistic, we set a cutoff MDW of 21.6. Multivariate logistic regression revealed that patients with an MDW≥21.6 had a higher risk of severe cholecystitis (odds ratio=4.94; 95 % CI, 1.71-14.21; p=0.003). The Cox model revealed that patients with an MDW≥21.6 were more likely to have a prolonged hospital stay.

CONCLUSIONS

MDW is a reliable indicator of severe cholecystitis and prolonged length of stay. Additional MDW testing and a complete blood count may provide simple information for predicting severe cholecystitis early.

Factors Affecting Early Cholecystectomy for Acute Cholecystitis in Older People-A Population-Based Study

OBJECTIVES

Acute cholecystitis is one of the most common surgical presentations in Australia and increases with age. Guidelines recommend early laparoscopic cholecystectomy (within 7 days), as it results in shorter length of stay, reduced costs and readmission rates. Despite this, there is a perception that early cholecystectomy may result in higher morbidity and conversion to open surgery in older patients. Our objective is to report the proportion of early versus delayed cholecystectomy in older patients in New South Wales (NSW), Australia, and to compare health outcomes and factors influencing variation.

DESIGN

This is a retrospective population-based cohort study of all cholecystectomies for primary acute cholecystitis in NSW residents aged >50, between 2009 and 2019. The primary outcome was the proportion of early versus delayed cholecystectomy. We used multilevel multivariable logistic regression analyses adjusted for age, sex, comorbidities, insurance status, socio-economic status and hospital characteristics.

RESULTS

A high rate (85%) of the 47,478 cholecystectomies in older patients were performed within 7 days of admission. Delayed surgery was associated with increasing age and comorbidity, male sex, Medicare-only insurance and surgery in low- or medium-volume centres. Early surgery was associated with shorter overall length of stay, fewer readmissions, less conversion to open surgery and lower bile duct injury rates.

CONCLUSION

A high proportion of adults with cholecystitis are undergoing early cholecystectomy in NSW. Our results support the efficacy of early cholecystectomy in older patients and identify potentially modifiable factors relevant to health care professionals and policymakers.

Clinical significance of preoperative antibiotic use in mild to moderate acute inflammatory gallbladder disease: A randomized controlled trial

BACKGROUND

Many patients receive empirical antibiotics for the prevention of postoperative infectious complications following cholecystectomy due to acute cholecystitis (AC). The purpose of this study was to investigate the clinical significance of preoperative antibiotics in mild to moderate AC patients undergoing emergency laparoscopic cholecystectomy.

METHODS

This was a double-blind, placebo-controlled, randomized study. Patients with AC eligible for emergency laparoscopic cholecystectomy were randomly assigned to an antibiotic or a placebo group. Clinical outcomes including infectious complications were reviewed.

RESULTS

An imputed per-protocol analysis of 234 patients showed that the postoperative infection rate was 8.6% (10 of 116 patients) in the antibiotic group and 7.6% (9 of 118 patients) in the placebo group (absolute difference, 1%; 95% CI: -8.1% to 6.1%; P = .815). Based on a noninferiority margin of 10%, the lack of preoperative antibiotic treatment was not associated with worse clinical outcomes than antibiotic treatment. Surgical site infection was the most common complication among the infectious complications, and there was no significant difference between the two groups (7.8% in the antibiotic group vs 7.6%, in the placebo group, P = .53).

CONCLUSIONS

The absence of prophylactic antibiotics has no significant impact on the incidence of infectious complications in mild to moderated AC.

Timing of Elective Cholecystectomy After Acute Cholecystitis: A Population-based Register Study

BACKGROUND

Acute cholecystectomy is standard treatment for acute cholecystitis. However, many patients are still treated conservatively and undergo delayed elective surgery. The aim of this study was to determine the ideal time to perform an elective cholecystectomy after acute cholecystitis.

METHODS

All patients treated for acute cholecystitis in Sweden between 2006 and 2013 were identified through the Swedish Patient Register. This cohort was cross-linked with the Swedish Register for Gallstone Surgery, GallRiks, where information on surgical outcome was retrieved. The impact of the time interval after discharge from hospital to elective surgery was analysed by multivariate logistic regression adjusting for gender and age.

RESULTS

After exclusion of patients not subjected to surgery, not registered in GallRiks and patients treated with acute cholecystectomy, 8532 remained. This cohort was divided into six-time categories. Using the first time interval < 11 days from discharge to elective surgery as the reference category the chance of completing surgery with a minimally invasive technique was increased for all categories (p < 0.05). The risk for perioperative complication and cystic duct leakage was reduced if surgery was undertaken > 30 days after discharge (both p < 0.05). The risk for bile duct injury was significantly increased if the procedure was undertaken > 365 days after discharge (p = 0.030). The chance of completing the procedure within 100 min was not affected by time.

CONCLUSION

For patients undergoing elective cholecystectomy after acute cholecystitis, the safety of the procedure increases if surgery is performed more than 30 days after discharge from the primary admission.

Acute acalculous cholecystitis in an infant after gastroschisis closure

Gastroschisis is a common type of congenital anterior abdominal wall defect with intraabdominal organs exposed outside the abdominal cavity. With modern neonatology and surgical practices, the overall prognosis for infants with gastroschisis is excellent. However, a subset of infants with gastroschisis will develop complications, requiring repeat surgical interventions. We present a case of a female infant with complicated gastroschisis who developed acute perforated acalculous cholecystitis, which was accurately diagnosed with abdominal ultrasound and successfully treated with medical management and a percutaneous cholecystostomy tube.

Is combined rather than single antibiotic therapy actually reasonable in patients with acute calculous cholecystitis?

OBJECTIVE

Acute calculous cholecystitis (AC) is a frequently encountered emergency surgery disease and its standard treatment is cholecystectomy. In patients with high risk in surgery, antibiotic treatment (AT) is important. In routine clinical practices, antibiotics are frequently used either as single or in combination in the treatment of AC. This study examined whether or not combined antibiotic treatment (CAT) had superiority over single antibiotic treatment (SAT) in AC.

METHODS

Patients with cholecystitis who received treatment in the period of 2016-2019 were retrospectively examined. The treatment procedures applied, patient findings, and laboratory data were analyzed using relevant statistical software. The patients were categorized into groups based on the treatment approaches applied, and the effects of SAT and CAT on infection parameters were analyzed.

RESULTS

In all, 184 patients received treatment for AC, with a mean age of 57.7, and the female-to-male ratio was 77:107. Of these, 139 patients received SAT and 45 received CAT. No significant difference was found in terms of effectiveness between the SAT and CAT in the patients who received early cholecystectomy treatment and those who received medical treatment with noninvasive intervention.

CONCLUSIONS

In patients with AC, antibiotics are commonly used either as single or in combination for prophylaxis and therapeutic purposes. As no significant difference was observed between single and combined use in terms of treatment effectiveness and hospitalization duration, CAT is not recommended due to its possibility of allergic side effects, toxicity, and cost-increasing effects.

Antibiotics for adults with acute cholecystitis or acute cholangitis or both

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms of antibiotics treatment versus placebo, no intervention, or another antibiotic for people with cholecystitis or cholangitis, or both.

Enhanced Recovery After Emergency Surgery: Utopia or Reality?

Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

Percutaneous cholecystostomy - An option in selected patients with acute cholecystitis

While urgent percutaneous cholecystostomy (PC) was introduced as an alternative to acute surgical treatment for acute cholecystitis (AC), the current place of PC in the treatment algorithm for AC is challenged. We evaluate demographics and outcomes of PC in routine clinical practice in a population-based cohort.Retrospective evaluation of consecutive patients treated with PC for AC between 2000 and 2015. The severity of cholecystitis was graded according to the 2013 Tokyo Guidelines.One hundred forty-nine patients were included (82; 55% males) (median age of 72.5 years; range, 21-92). The Tokyo Guidelines criteria of 2013 (TG13) severity grade distribution was 4%, 61.7%, and 34.2% for grades I, II, and III, respectively. No difference was observed between males and females with regard to age, American Society of Anesthesiologists (ASA) score, comorbidities, or previous history of cholecystitis. PC was successfully performed in all but 1 patient, and complications were few and minor. Less than half (48.3%) of all patients subsequently received definitive surgical treatment, mostly (83.3%) laparoscopy. No or minor complications were encountered in 58 (80.6%) patients. Operated patients were significantly younger (P = <.001) and had lower ASA scores (P = .005), less comorbidities (P < .001), and had more seldomly a severe grade 3 cholecystitis (P < .001) than non-operated patients.PC is useful in selected patients with AC. However, since only a half of the patients eventually received definitive surgical treatment, a better routine decision-making based on proper criteria may enable an improved allocation of the individual patient for tailored treatment according to the disease severity, the patient's comorbidity burden, and also to the treatment options available at the institution to prevent overutilization of a non-definitive treatment approach. Comprehension of this responsibility should be acknowledged by hospitals with an emergency surgical service, although the clinical decision-making remains a challenge of the responsible surgeon on call.

[Emergency Surgery and Trauma Care During COVID-19 Pandemic. Recommendations of the Spanish Association of Surgeons]

La infección por el nuevo coronavirus SARS-CoV-2 (enfermedad por coronavirus 2019 [COVID-19]) ha determinado la necesidad de la reorganización de muchos centros hospitalarios en el mundo. España, como uno de los epicentros de la enfermedad, ha debido asumir cambios en la práctica totalidad de su territorio. Sin embargo, y desde el inicio de la pandemia, en todos los centros que atienden urgencias quirúrgicas ha sido necesario el mantenimiento de su cobertura, aunque igualmente ha sido inevitable introducir directrices especiales de ajuste al nuevo escenario que permitan el mantenimiento de la excelencia en la calidad asistencial. Este documento desarrolla una serie de indicaciones generales para la cirugía de urgencias y la atención al politraumatizado desarrolladas desde la literatura disponible y consensuadas por un subgrupo de profesionales desde el grupo general Cirugía-AEC-COVID-19. Estas medidas van encaminadas a contemplar un riguroso control de la exposición en pacientes y profesionales, a tener en cuenta las implicaciones de la pandemia sobre diferentes escenarios perioperatorios relacionados con la urgencia y a una adaptación ajustada a la situación del centro en relación con la atención a pacientes infectados.

Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters

BACKGROUND

Laparoscopic cholecystectomy (LC) is often performed during the index admission after emergency presentation for acute biliary pain. Many patients have acute cholecystitis (AC) that may increase operative difficulty and complications. Our primary aim was to assess the validity of Tokyo Guidelines (TG18) for diagnosing AC by comparison with the admitting team diagnosis, operative findings and histopathology. The secondary aim was to assess outcomes after same-admission or delayed LC.

METHODS

Retrospective analysis of patients who underwent LC after presenting to a tertiary hospital emergency department over a 12-month period was conducted.

RESULTS

A total of 139 patients underwent LC with no mortality or bile duct injury. A diagnosis of AC made by the admitting surgical team had sensitivity of 84% and specificity of 57%. The TG18 diagnosis had sensitivity of 84% and specificity of 53%. A diagnosis of AC by the admitting surgical team correlated well with TG18 criteria diagnosis. There was poor correlation between clinical and histopathological diagnoses. Nine percent of patients had complications and 4% required conversion to open procedure. Patients with a clinical diagnosis of AC had longer post-operative length of stay and more complications compared with those who had non-AC diagnosis. There was no difference in outcomes between same-admission LC or delayed LC.

CONCLUSION

TG18 diagnosis of AC does not improve accuracy of diagnosis or predictability of a poor outcome over the admitting surgical team diagnosis. Same-admission LC for patients with AC is associated with similar outcomes compared to those who undergo delayed LC.

Failure to perform index cholecystectomy during acute cholecystitis results in significant morbidity for patients who present with recurrence

BACKGROUND

Although index cholecystectomy is considered the treatment of choice for acute cholecystitis (AC), many hospital systems struggle to provide such a service. The aim of this study was to analyze the effect of failure to perform index cholecystectomy in patients presenting with acute cholecystitis.

METHODS

Between June 2010 and December 2015, all patients presenting to one hospital with an initial attack of AC were enrolled into a prospective database. Patient's records were reviewed up until point of delayed cholecystectomy or for a minimum of 24 months after the initial presentation with AC. Recurrent AC was defined as early (<6 weeks from initial discharge) or late (>6 weeks from initial discharge).

RESULTS

In total 998 patients presented with AC, 409 (41%) of whom were discharged without index cholecystectomy. Eighty-three (20%) patients presented with AC recurrence (ACR). Compared to the first AC episode, patients were more likely to present with grade III AC and suffer significantly greater morbidity (p < 0.05 for all comparisons). A prior history of biliary disease was associated with ACR (p = 0.002). ACR occurred early in 48 (58%) patients and delayed in 35 (42%) patients.

CONCLUSIONS

Twenty percent of patients discharged without cholecystectomy after their first attack of ACR will develop recurrence within the first two years. Half of ACR will occur within 6 weeks. Patients who present with ACR are more likely to develop more severe AC and are likely to suffer greater morbidity as compared to their first attack.

Extended Postoperative Antibiotics Versus No Postoperative Antibiotics in Patients Undergoing Emergency Cholecystectomy for Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis

Objectives. To compare the outcomes of extended postoperative antibiotics versus no postoperative antibiotics in patients with acute calculous cholecystitis undergoing emergency cholecystectomy. Methods. We performed a systematic review and conducted a search of electronic information sources to identify all randomized controlled trials comparing outcomes of extended postoperative antibiotics versus no postoperative antibiotics in patients with acute calculous cholecystitis undergoing emergency cholecystectomy. Postoperative infectious complications and surgical site infections were primary outcome measures. The secondary outcome measures included postoperative morbidity, postoperative noninfectious complications, urinary tract infections, pneumonia, length of hospital stay, postoperative mortality, and need for readmission. Random or fixed effects modeling was applied to calculate pooled outcome data. Results. Four randomized controlled trials enrolling 953 patients were identified. The included populations in the extended antibiotic group and no antibiotic group were comparable in terms of baseline characteristics. There was no difference between the 2 groups in terms of postoperative infectious complications (odds ratio [OR] =0.94, P = .79), surgical site infections (OR = 1.13, P = .72), postoperative morbidity (OR = 0.93, P = .70), postoperative noninfectious complications (OR = 0.85, P = .57), urinary tract infections (OR = 0.69, P = .55), pneumonia (OR = 0.33, P = .14), length of hospital stay (mean difference = 0.78, P = .25), postoperative mortality (risk difference = -0.00, P = .65), and need for readmission (OR = 0.87, P = .70). Conclusions. Our results suggest that extended postoperative antibiotic therapy does not improve postoperative infectious or noninfectious outcomes in patients with mild or moderate acute calculous cholecystitis undergoing emergency cholecystectomy. Postoperative antibiotics should not be routinely used and should be preserved only for selected cases.

Acute acalculous cholecystitis in children

Acute acalculous cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. AAC is estimated to represent at least 50% to 70% of all cases of acute cholecystitis during childhood. Although this pathology was originally described in critically ill or post-surgical patients, most pediatric cases have been observed during several infectious diseases. In addition to cases caused by bacterial and parasitic infections, most pediatric reports after 2000 described children developing AAC during viral illnesses (such as Epstein-Barr virus and hepatitis A virus infections). Moreover, some pediatric cases have been associated with several underlying chronic diseases and, in particular, with immune-mediated disorders. Here, we review the epidemiological aspects of pediatric AAC, and we discuss etiology, pathophysiology and clinical management, according to the cases reported in the medical literature.

Extended antibiotic therapy versus placebo after laparoscopic cholecystectomy for mild and moderate acute calculous cholecystitis: A randomized double-blind clinical trial

BACKGROUND

Acute calculous cholecystitis (ACC) is the most common complication of cholelithiasis. Laparoscopic cholecystectomy (LC) is the gold standard treatment in mild and moderate forms. Currently there is consensus for the use of antibiotics in the preoperative phase of ACC. However, the need for antibiotic therapy after surgery remains undefined with a low level of scientific evidence.

METHODS

The CHART (Cholecystectomy Antibiotic Randomised Trial) study is a single-center, prospective, double blind, and randomized trial. Patients with mild to moderate ACC operated by LC were randomly assigned to receive antibiotic (amoxicillin/clavulanic acid) or placebo treatment for 5 consecutive days. The primary endpoint was postoperative infectious complications. Secondary endpoints were as follows: (1) duration of hospital stay, (2) readmissions, (3) reintervention, and (4) overall mortality.

RESULTS

In the per-protocol analysis, 6 of 104 patients (5.8%) in the placebo arm and 6 of 91 patients (6.6%) in the antibiotic arm developed postoperative infectious complications (absolute difference 0.82 (95% confidence interval, -5.96 to 7.61, P = .81). The median hospital stay was 3 days. There was no mortality. There were no differences regarding readmissions and reoperations between the 2 groups.

CONCLUSION

Although this trial failed to show noninferiority of postoperative placebo compared to antibiotic treatment after LC for mild and moderate ACC within a noninferiority margin of 5%, the use of antibiotics in the postoperative period does not seem justified, because it was not associated with a decrease in the incidence of infectious and other types of morbidity in the present study.

Human Bile Reduces Antimicrobial Activity of Selected Antibiotics against Enterococcus faecalis and Escherichia coli In Vitro

It has been known from previous studies that body fluids, such as cerebrospinal fluid, lung surfactant, and urine, have a strong impact on the bacterial killing of many anti-infective agents. However, the influence of human bile on the antimicrobial activity of antibiotics is widely unknown. Human bile was obtained and pooled from 11 patients undergoing cholecystectomy. After sterilization of the bile fluid by gamma irradiation, its effect on bacterial killing was investigated for linezolid (LZD) and tigecycline (TGC) against Enterococcus faecalis ATCC 29212. Further, ciprofloxacin (CIP), meropenem (MEM), and TGC were tested against Escherichia coli ATCC 25922. Time-kill curves were performed in pooled human bile and Mueller-Hinton broth (MHB) over 24 h. Bacterial counts (in CFU per milliliter after 24 h) of bile growth controls were approximately equal to MHB growth controls for E. coli and approximately 2-fold greater for E. faecalis, indicating a promotion of bacterial growth by bile for the latter strain. Bile reduced the antimicrobial activity of CIP, MEM, and TGC against E. coli as well as the activity of LZD and TGC against E. faecalis This effect was strongest for TGC against the two strains. Degradation of TGC in bile was identified as the most likely explanation. These findings may have important implications for the treatment of bacterial infections of the gallbladder and biliary tract and should be explored in more detail.

Acute calculous cholecystitis: Review of current best practices

Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis

Background

Many patients who have surgery for acute cholecystitis receive postoperative antibiotic prophylaxis, with the intent to reduce infectious complications. There is, however, no evidence that extending antibiotics beyond a single perioperative dose is advantageous. This study aimed to determine the effect of extended antibiotic prophylaxis on infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy.

Methods

For this randomized controlled non-inferiority trial, adult patients with mild acute calculous cholecystitis undergoing cholecystectomy at six major teaching hospitals in the Netherlands, between April 2012 and September 2014, were assessed for eligibility. Patients were randomized to either a single preoperative dose of cefazolin (2000 mg), or antibiotic prophylaxis for 3 days after surgery (intravenous cefuroxime 750 mg plus metronidazole 500 mg, three times daily), in addition to the single dose. The primary endpoint was rate of infectious complications within 30 days after operation.

Results

In the intention-to-treat analysis, three of 77 patients (4 per cent) in the extended antibiotic group and three of 73 (4 per cent) in the standard prophylaxis group developed postoperative infectious complications (absolute difference 0·2 (95 per cent c.i. –8·2 to 8·9) per cent). Based on a margin of 5 per cent, non-inferiority of standard prophylaxis compared with extended prophylaxis was not proven. Median length of hospital stay was 3 days in the extended antibiotic group and 1 day in the standard prophylaxis group.

Conclusion

Standard single-dose antibiotic prophylaxis did not lead to an increase in postoperative infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy. Registration number: NTR3089 (www.trialregister.nl).