World Journal of Laparoscopic Surgery
Volume 15 | Issue 3 | Year 2022

Bacterial Infection and Sensitivity Pattern of Cholecystitis among Cholecystectomy Patients

Sunil Kaval1, Swati Tewari2, Ekta Rani3

1Department of Surgery, Lala Lajpat Rai Memorial Medical College (Affiliated with Chaudhary Charan Singh University), Meerut, Uttar Pradesh, India

2,3Department of Microbiology, National Capital Region Institute of Medical Sciences (Affiliated with Chaudhary Charan Singh University), Meerut, Uttar Pradesh, India

Corresponding Author: Sunil Kaval, Department of Surgery, Lala Lajpat Rai Memorial Medical College (Affiliated with Chaudhary Charan Singh University), Meerut, Uttar Pradesh, India, +91 9927888997, e-mail: drswatitewari@gmail.com

How to cite this article: Kaval S, Tewari S, Rani E. Bacterial Infection and Sensitivity Pattern of Cholecystitis among Cholecystectomy Patients. World J Lap Surg 2022;15(3):211–214.

Source of support: Nil

Conflict of interest: None

Ethical statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Received on: 27 April 2022; Accepted on: 28 September 2022; Published on: 07 December 2022


Aims and objectives: This retrospective type of study was done to know the bacterial cause of cholecystitis and to isolate different bacteria present in bile of cholecystectomy patients. Antibiotic sensitivity was also done to know the antibiotic-resistance pattern among the organism isolated.

Materials and methods: In this study, 126 patients’ bile was sent to the Microbiology Department for culture and antibiotic-sensitivity testing during the period of October 2017–November 2018. Cultures were placed in blood agar and MacConkey agar. Organisms were isolated on the basis of growth characteristics and biochemical findings. Antibiotic sensitivity was done using the Kirby–Bauer disk-diffusion method.

Results: This study included 126 post-cholecystectomy patients, out of which the male-to-female ratio was 1:2.71. While the female was 92 (83%) and the male was 34 (17%). In this study, we have included all the age-groups of patients, but most of the patients were middle-aged, that is, between 41 and 60 years 78 (62%). In the microbiological analysis, only 68 (54%) samples were culture-positive. In our study, Escherichia coli 43 (63.2%) was isolated among maximum samples and the second most common was Klebsiella spp. 17 (25%).

Conclusion: Therefore, it is important to know about common bacteria causing gallbladder infection and their antibiotic-resistance pattern. This study may be helpful in designing the antibiotic prophylaxis among these patients.

Keywords: Analysis, Antibiotic sensitivity, Bile, Cholecystectomy.


Gallbladder stones are one of the most common surgical conditions in North India, and out of all surgeries done for the gastrointestinal tract, cholecystectomy is the most common.1 Bile is normally sterile, but may get infected in cholelithiasis. The incidence of bacterial presence in bile varies from 10 to 70%. Chances of Bactibilia are increasing in patients having obstruction and stasis of gallbladder due to gallstones.2 The gallstone diseases are more prevalent in Western countries like United States, United Kingdom, and Australia, and incidence ranges between 15 and 25%. In India, gallstones are more common in the East and northern parts of India as compared with the South and West regions.3,4 In 85–95% of cases, cholecystitis is associated with cholelithiasis.5

Among all the culture-positive samples of bile, the most common bacteria isolated were Escherichia and Klebsiella. The bacteriological profile of bile sampled from the gallbladder is more informative of the cause of cholecystitis because gallbladder is a closed sac, and direct sampling from the gallbladder is more relevant to know the causative organism.6,7

The study was done to know the most common bacteria associated with cholecystitis and their sensitivity pattern among cholecystectomy patients.


The retrospective type of study was done for one-year duration in tertiary care settings. In patients of open cholecystectomy, bile was collected in a sterile syringe, in the case of laparoscopic cholecystectomy, bile was collected in a sterile container. The syringe or container is sent to the Microbiology Department after proper labeling. In microbiology lab, bile samples were inoculated on blood agar and MacConkey agar, and incubated at 37°C for 24–48 hours. The bile was reported sterile if there was no growth even after 48 hours of incubation. All growth of cultures were identified on the basis of colony morphology, microscopic examination, and appropriate biochemical reactions. Antimicrobial-susceptibility testing was done by Kirby–Bauer method according to Clinical and Laboratory Standard Institute (CLSI) Guidelines.8,9


This study included a total of 126 patients among which male-to-female ratio was 1:2.71. While female was 92 (83%) and male was 34 (17%). We have included all ages of patients in our study, in which maximum patients were in 41–60 age-group, 78 (62%) followed by 25 (19.8%) in the age-group >61, 22 (17.4%) in 21–40 age-group, and 1 (0.8%) in 01–20 age-group (Figs 1 and 2, Table 1). Out of 126 patients, 96 (76.2%) patients underwent laparoscopy cholecystectomy, in 18 (14.3%) patients, open cholecystectomy was performed, and in 12 (9.5%), laparoscopy surgery was converted to open surgery (Fig. 3).

Figs 1A to C: (A) Gallbladder with multiple stones; (B) Intact gallbladder; and (C) Cholesterosis of gallbladder

Fig. 2: Sex distribution

Fig. 3: Distribution of surgical treatment procedure

Table 1: Age-group-wise distribution
Sl. no. Age-group Total %
1. 01–20 01 (0.8%)
2. 21–40 22 (17.4%)
3. 41–60 78 (62%)
4. >61 25 (19.8%)

Out of 126 bile samples for culture and sensitivity, only 68 (54%) samples were culture-positive. E. coli 43 (63.2%) was the most common isolate followed by Klebsiella spp. 17 (25%). Other organisms isolated were 4 (6%) Pseudomonas spp., 2 (3%) Salmonella spp. and Staphylococcus aureus, and Acinetobacter 1 (1.4%) each. The remaining bile samples 58 (46%) were sterile (Fig. 4).

Fig. 4: Bacteriological profile of bile

All Gram-negative bacterial isolates showed maximum sensitivity toward imipenem, meropenem, piperacillin/tazobactam, cefepime, and ceftriaxone/sulbactam. No organism was found to be resistance to colistin and polymyxin B. Among gram-positive, bacterial isolates showed sensitivity to linezolid and teicoplanin (Table 2).

Table 2: Antibiogram of the bacteria isolated
Antibiotic Resistance
E. coli Klebsiella spp. Pseudomonas spp. Salmonella spp. Acinetobacter spp. S. aureus
Piperacillin 43 (100%) 17 (100%) 4 (100%) 2 (100%) 1 (100%)
Ceftazidime 22 (51.2%) 17 (100%) 4 (100%) 1 (50%) 1 (100%)
Ceftriaxone 22 (51.2%) 17 (100%) 4 (100%) 1 (50%) 1 (100%) 1 (100%)
Cefoperazone 22 (51.2%) 17 (100%) 4 (100%) 1 (50%) 1 (100%) 1 (100%)
Gentamicin 43 (100%) 10 (58.8%) 3 (75%) 2 (100%) 1 (100%)
Amikacin 43 (100%) 10 (58.8%) 3 (75%) 2 (100%) 1 (100%)
Ciprofloxacin 43 (100%) 14 (82.3%) 2 (50%) 2 (100%) 1 (100%) 1 (100%)
Levofloxacin 43 (100%) 14 (82.3%) 2 (50%) 2 (100%) 1 (100%) 1 (100%)
Imipenem 0 8 (47%) 1 (25%) 0 1 (100%) 0
Meropenem 0 8 (47%) 1 (25%) 0 1 (100%) 0
Chloramphenicol 0 0
Cefixime 1 (100%)
Colistin 0 0 0 0 0
Polymyxin B 0 0 0 0 0
Piperacillin/Tazobactam 0 10 (58.8%) 1 (25%) 0 0
Ceftriaxone/Sulbactam 0 10 (58.8%) 1 (25%) 0 0
Cefepime/Tazobactam 0 10 (58.8%) 1 (25%) 0 0
Doxycycline 4 (100%) 0
Aztreonam 0
Erythromycin 1 (100%)
Clindamycin 1 (100%)
Linezolid 0
Teicoplanin 0
Vancomycin 0
Rifampicin 0


This study includes 126 patients admitted to our surgery unit over a period of 1 year. In this, 54% bile samples showed positive bile culture. The data showed high prevalence in western Uttar Pradesh. Our finding contrasts with other researchers. They reported very low prevalence.1012

In this study, most of the cases were of middle-age-group that is between 41 and 60 years, that is similar to other studies. Chuttani et al. reported maximum incidence of cholelithiasis in-between 31 and 60 years.36,13 In our study, 17% were males and 83% were females, and male-to-female ratio was 1:2.71. Similar female predominance has been reported by many researchers.1116 The most common organism isolated in bile culture was E. coli 63.2%, and the second most common was Klebsiella spp. in 25% of the patients. Our findings were similar to other studies published by Capoor et al., Bhansali et al., Cristina et al., Sharma et al., Pratik et al., and many more, the most common organism isolated was E. coli followed by Klebsiella spp. As E. coli and Klebsiella both are the most common bacteria isolated in the bile culture as they are the commonest bacteria found in GIT and infection to the biliary system comes from the GIT.1722

Our study was similar to Gupta et al., Khalid Anjum et al., Kumar et al., Manan et al., Bhansali et al., Flores et al., Pratik et al., and Fuks et al.2,11,13,16,1923


Normally, bile is sterile in the gallbladder in the absence of gallstone or any pathology of the biliary tract. There is high incidence of bacteribilia in cases of the inflamed gallbladder with gallstones or biliary tract obstruction. Gram-negative organisms are more common in bile infection as they are part of normal GI flora and may cause ascending infection in the gallbladder. Drug resistance is a growing health problem, nowadays, undue and inappropriate use of antibiotics are the main cause of growing drug resistance.


1. Gill HS, Sandhu GS, Luna A, et al. Bacteriological profile of bile in patients undergoing cholecystectomy. Sch Acad J Biosci 2016;4(6):520–525. DOI: 10.21276/sajb.2016.4.6.12.

2. Gupta J, Gupta A, Gupta R, et al. Bacteriological profile of bile and antibiogram in cholecystectomy patients. J Med Sci Clin Res 2017;5(4):20786–20789. DOI: 10.18535/jmscr/v5i4.169.

3. Ballal M, Jyothi KN, Antony B, et al. Bacteriological spectrum of cholecystitis and its antibiogram. Indian J Med Microbiol 2001;19(4):212–214. PMID: 17664836.

4. Thompson JE Jr, Pitt HA, Doty JE, et al. Broad spectrum penicillin as an adequate therapy for acute cholangitis. Surg Gynecol Obstet 1990;171(4):275–282. PMID: 2218831.

5. Kaur D, Gupta V, Chhina RS, et al. Microbiological profile of biliary tract infections. J Gastrointest Infect 2015;5(1):20–23. DOI: 10.5005/jp-jogi-5-1-20.

6. Yun SP and Seo HI. Clinical aspects of bile culture in patients undergoing laparoscopic cholecystectomy. Medicine (Baltimore) 2018;97(26):e11234. DOI: 10.1097/MD.0000000000011234.

7. Kwon W, Jang JY, Kim EC, et al. Changing trend in bile microbiology and antibiotic susceptibilities: Over 12 years of experience. Infection 2013;41(1):93–102. DOI: 10.1007/s15010-012-0358-y.

8. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-seventh Informational Supplement. CLSI document. M100-S20. Pennsylvania: Clinical and Laboratory Standards Institute; 2017.

9. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-fourth Informational Supplement. Wayne, Pennsylvania, USA; 2014.

10. van Leeuwen PA, Keeman JN, Butzelaar RM, et al. Correlation between a positive gallbladder culture and subsequent wound infection after biliary surgery: A retrospective study of 840 patients. Neth J Surg 1985;37(6):179–182. PMID: 3911113.

11. Md Khalid Anjum, Amber Prasad, Makbul Ansari, et al. Bacteriological profile of bile in cholecystectomy patients at Rims, Ranchi, India. Int J Curr Microbiol Appl Sci 2020;9(6):156–160. DOI: 10.20546/ijcmas.2020.906.020.

12. José Eleuterio González, Rubén Cueto-Ramos, Marco Hernández-Guedea, et al. Incidence of bacteria from cultures of bile and gallbladder wall of laparoscopic cholecystectomy patients in the University Hospital. Cirugía y Cirujanos 2017;85(6):515–521. DOI: 10.1016/j.circen.2016.10.009.

13. Kumar M, Oraon V, Sherwal BL, et al. Bacterial profile of bile and gall stone in symptomatic cholelithiasis patients. Int J Med Res Prof 2017;3(3):122–126. Doi: 10.21276/ijmrp.2017.3.3.026.

14. Ahmad F, Islahi S, Hingora OM, et al. Cholelithiasis – A clinical and microbiological analysis. Int J Sci Stud 2014;2(4):40–45.

15. Sabharwal ED, Chopra R, Chawla LS. Gall bladder disease pattern in Punjab. J Indian Med Assoc 1984;82(5):164–166. PMID: 6481174.

16. Manan F, Khan MA, Faraz A, et al. Frequency of common bacteria and their antibiotic sensitivity in patients with symptomatic cholelithiasis. J Postgraduate Med Instit 2014;28(2):177–183.

17. Chhutani PN, Sachdeva Y, Chitkara NL, et al. Gall bladder disease in Punjab: Incidence and symptomatology. J Assoc Physicians India 1965;13:140–145. PMID: 14263397.

18. Capoor MR, Nair D, Khanna G, et al. Microflora of bile aspirates in patients with acute cholecystitis with or without cholelithiasis: A tropical experience. Braz J Infect Dis 2008;12(3):222–225. DOI: 10.1590/s1413-86702008000300012.

19. Bhansali SK. Preoperative complications of gallstones and their relevance to treatment and prognosis: Experience with 451 cases. Am J Gast 1985;80(8):648–654. PMID: 4025282.

20. Flores C, Maguilnik I, Hadlich E, et al. Microbiology of choledochal bile in patients with choledocholithiasis admitted to a tertiary hospital. J Gastroenterol Hepatol 2003;18(3):333–336. DOI: 10.1046/j.1440-1746.2003.02971.x.

21. Sharma K, Jad B, Mahajan B, et al. Bacteriological analysis of bile culture from a tertiary care hospital. Int J Health Sci Res 2018;8(5):88–91.

22. Pratik MP, Nimish JS, Pokhraj PS, et al. Bacteriological analysis of bile in cholecystectomy patients. Int J Res Med Sci 2015;3(11):3091–3096. DOI: 10.18203/2320-6012.ijrms20151142.

23. Fuks D, Cossé C, Régimbeau JM. Antibiotic therapy in acute calculous cholecystitis. J Visc Surg 2013;150(1):3–8. DOI: 10.1016/j.jviscsurg.2013.01.004.

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