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Year : 2001  |  Volume : 19  |  Issue : 4  |  Page : 212-214

Bacteriological spectrum of cholecystitis and its antibiogram

Department of Microbiology, Kasturba Medical College, Manipal - 576 119, Karnataka, India

Correspondence Address:
Department of Microbiology, Kasturba Medical College, Manipal - 576 119, Karnataka, India

 ~ Abstract 

Bile Cultures for aerobic and anaerobic bacteria were carried out on 125 samples from patients with chronic cholecystitis with cholelithiasis. Cultures grew 71(56.8%) aerobes and 17(13.6%) anaerobic microorganisms. Polymicrobial infection was seen in 7(16.2%) cases. E. coli (45.07%) and Klebsiella (25.35%) were predominant among the aerobes and Bacteroides fragilis (58.82%) was predominant among the anaerobes. Highest incidence of the disease was observed in the fourth decade of life and females predominated in this study.

How to cite this article:
Ballal M, Jyothi K N, Antony B, Arun C, Prabhu T, Shivananda P G. Bacteriological spectrum of cholecystitis and its antibiogram. Indian J Med Microbiol 2001;19:212-4

How to cite this URL:
Ballal M, Jyothi K N, Antony B, Arun C, Prabhu T, Shivananda P G. Bacteriological spectrum of cholecystitis and its antibiogram. Indian J Med Microbiol [serial online] 2001 [cited 2021 Mar 5];19:212-4. Available from:

Cholecystitis and cholelithiasis with its complications dominate the disease of the biliary tract. Gall bladder disease has a wide geographic variation, being common in the US where an estimated 15 million people have gall stones and of these 1/5th or 3 million undergo biliary tract operations every year.[1]
Although reports of cholecystitis in India have been well documented,[2],[3],[4] data on overall incidence of this condition among our population particularlyin the Coastal Karnataka is scanty. Considerable controversy still exists as to the exact role of the infection in cholecystitis.
The present study was carried out to determine the exact incidence and nature of the biliary tract infection, to find out the microbial flora in the bile of patients with cholecystitis and cholelithiasis and also to study their antibiotic susceptibility patterns. We have also tried to postulate on the probable etiological association of microorganisms with the disease.

 ~ Materials and Methods Top

Bile samples were collected from 125 patients diagnosed as cases of chronic cholecystitis with or without cholelithiasis when undergoing cholecystectomy.
Presenting signs & symptoms
Abdominal pain, varying in intensity from mild to severe, was the major complaint in 97% of patients. The pain while most frequently located in the right upper quadrant was sometimes noted in the epigastrium and occasionally in the left upper quadrant. Nausea and/or vomiting was present in 8 patients. There were 21 patients with jaundice at the time of admission.
Laboratory data
Laboratory examination was of little diagnostic value except when the patient was having jaundice. The diagnosis of cholecystitis and cholelithiasis was established by an oral cholecystogram. 25 patients had stones shown in cholecystogram.
The age, sex and clinical features of the patients and the relevant information were also recorded. Bile samples from 25 patients without any history of cholelithiasis/cholecystitis were taken as control group.
Cholecystectomy was done in 82 patients, in the rest 43 patients, cholecystectomy with common bile duct exploration was done. At operation, bile for culture was taken either from common bile duct or from the gall bladder. Cultures were performed within an hour of surgery. In most of the cases, the bile samples appeared turbid and in 3 cases it was found to be purulent and all these correlated well with culture positivity also.
About 3 mL of bile sample was inoculated into the bile broth, Selenite F broth, blood agar, MacConkey's agar and Robertson's cooked meat medium and incubated at 370C for 24 hours.
The portion of the stones submitted for bacterial cultures was washed with normal sterile saline to remove surface contaminants. The stones were then crushed and inoculated onto a blood agar plate and MacConkey's agar plate.
Biochemical analysis of the 25 gall stones was done. Mixed stones (infection stones) were predominant (14.56%), pure cholesterol stones and pigment stones formed 24% and 20% respectively.
Bacteria isolated (both anaerobically and aerobically) were identified and the antibiogram pattern of the isolates carried out using standard technique.[5],[6],[7]

 ~ Results Top

A total of 125 bile samples along with 25 gall stones were processed for both aerobic and anaerobic microorganisms. Bile cultures grew bacteria in 88(70.4%) of 125 patients out of which 71(56.8%) were aerobes and the remaining 17(13.6%) were anaerobes. Results of bacteriological analysis of bile samples and gall stones are given in [Table - 1]. Mixed bacterial flora was seen in 7 cases [Table - 2]. Among the mixed flora, 2 had only aerobes and the remaining 5 had both aerobes and anaerobes in them.
Of the 25 gall stones processed, 6 yielded growth of aerobic bacteria which were similar to the isolates in bile cultures from the same patients. All cultures were negative in the control group.
Analysis of the bacterial flora showed that  Escherichia More Details coli was the most common isolate both in bile as well as in gall stones which was isolated either singly or in association with other organisms in clinical specimens.
 Salmonella More Details typhi was isolated from 2 bile samples followed by Klebsiella. Maximum isolates 34(45.4%) were seen in age groups between 51-60 years. The antibiogram of the isolates are also summarised [Table - 3].

 ~ Discussion Top

Diseases of the gall bladder which mainly comprise of cholecystitis and cholelithiasis are prevalent in certain regions of the world and quite rare at other places.[8] This is also called as South Western American disease and has been reported in 54% of the adults above 21 years of age.[9] In India, exact figures of averall incidence of cholelithiasis are not available and as a whole is less common. But its incidence is quite high in Bengal. A bacterial cause of cholecystitis has been proposed and positive bile cultures have been noted in 60% of patients with acute cholecystitis. Interest has continued to abound in the role of infection in cholelithiasis. Two fallacies, however, exist in this regard.
(a) Firstly, the culture of the organism from the bile at the time of the operation does not necessarily indicate a cause-effect relationship between the infective microorganism and lithogenesis, as infection may be secondary to calculus formation.
(b) Secondly, the failure to isolate organism from bile also does not indicate that the etiology is unrelated to the infection as it is well known that organism which have initiated the stone precipitation may not persist in the viable form in the bile till surgery.[2],[10]
 Escherichia More Details coli was found to be the commonest organism in our study as already been reported elsewhere.[10],[11],[12],[13] However, Pseudomonas has been reported as the predominant flora by Dhir et al.[3] 11 out of 13 instances where E coli was grown were found to be sensitive to ampicillin which appears to be a good choice for chemoprophylaxis.
The importance of the predominance of E coli is seen by the fact that studies by Maki (1966) has shown that glucosonidase enzymatic activity of E coli may have a role to play in calcium bilirubinate gall stone formation. However, this type of gall stone is uncommon in India.[3],[14]
In our study, both instances where  Salmonella More Details typhi had grown, it was sensitive to choloramphenicol, ampicillin and ciprofloxacin. Sexwise analysis of the patients with cholecystitis showed that it was common in females than in males as reported elsewhere. Its high incidence in females have been attributed to hormonal effects related to menstrual cycle and pregnancy.
Studies elsewhere have proved that normal bile is sterile as is our experience with 25 cases of normal bile cultured from the control group.
The anaerobes were found to be sensitive to metronidazole, cefotaxime, cefazolin, chloramphenicol and tetracycline. The aerobes isolated in our study were found to be sensitive to ampicillin, chloramphenicol, gentamicin, streptomycin, tetracycline and second generation fluoroquinolones like ciprofloxacin and norfloxacin.
Thus, we have shown that the importance of obtaining cultures of the bile at the time of cholecystectomy lies in the fact that appropriate antibiotics can be administered in the event of a positive culture to forestall serious complications like gram negative septicaemia. Regarding the etiological association between infection and stone formation, studies have shown that mucoprotein content of bile in patients with cholelithiasis is significantly higher than in normal controls and high proportion of nuclei of these stones contain protein on biochemical or histochemical analysis.[15],[16]
In case of cholecystitis and cholelithiasis, antibiotics can be started subsequently if the clinical situation or the culture reports warrant. Routine culture of all bile samples is, however mandatory. 

 ~ References Top

1.Flemma RJ, Flint LM, Osterhout S, Shingleton WW. Bacteriologic studies of biliary tract infection. Ann Surg 1967;166:563-572.  Back to cited text no. 1    
2.Lygidakis NJ. Incidence of bile infection in patients with Choledocholithiasis. Am J Gastroenterol 1982;77:12-17.  Back to cited text no. 2    
3.Vinay DV, Swaroop S, Kelkar R Bile microflora and antibiotic sensitivity patterns in malignant obstructive jaundice. Ind J Gastroentero 1991;10:15-20.  Back to cited text no. 3    
4.Saxena R, Kumar P etal. Spectrum of benign biliary disease as seen in Chandigarh. Ind J Surg 1991;53:347-358.  Back to cited text no. 4    
5.Trevor Willis A. Anaerobic Bacteriology: Clinical and Laboratory Practice. 3rd ed (London Butterworths).  Back to cited text no. 5    
6.Agarwal KC. Antibiotic susceptibility test by disc diffusion method. Standardisation and interpretation. Indian J Pathol Bacteriol 1974;17:148-150.  Back to cited text no. 6    
7.Kala ZS, Wani NA, Masger MS, Rashid PA. Clinical study of Cholecystitis in Kashmir. Ind J Surg 1977;21: 530-532.  Back to cited text no. 7    
8.Toouli J Surgery of the biliary tract, Churchill Livingstone, Edinburgh 1993.  Back to cited text no. 8    
9.Ananth K, Kapur BML. Chronic cholecystitis and biliary infection. Ind J Surg 1983;45:411-413.  Back to cited text no. 9    
10.Mukerjee NS, Dey NC. Studies on bile culture and antibiotic sensitivity tests in 100 cases of Cholecystitis. J Ind Med Assoc 1968;50:417-420.  Back to cited text no. 10    
11.Prakash A, Varma KN, Kappor M. Prakash OM. Diseased gall bladder in India. Ind J Surg 1974;59:214-216.  Back to cited text no. 11    
12.Prakash A, Varma KN, Kapor M, Prakash OM. Role of E coli in acute Cholecystitis, an experimental study. Ind J Surg 1969;31:205-207.  Back to cited text no. 12    
13.Cheslyn CS, Russell RCG. New trends in gall stone management. Br J Surg 1991;78:143-149. Ann Surg 1966;164: 90-100.  Back to cited text no. 13    
14.Nagase M H, Tanimura M, Setoyama, Hikasa Y. Present features of gall stones in Japan. A collective review in 2144 cases. Am J Surg 1978;135:788-790.  Back to cited text no. 14    
15.Leung JWC, Sung JY, Costerton JW. Bacteriological and Electron Microscopy examination of brown pigment stones J Clin Microbiol 1989;27:915-921.  Back to cited text no. 15    
16.Malet PF, Williamson CE, Trotman BW, Soloway RD. Composition of pigmented centres of cholesterol gall stones. Hepatology 1986;6:477-481.  Back to cited text no. 16    
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