Abstract/Text
BACKGROUND: Pyogenic liver abscess, a potentially life-threatening disease, has undergone significant changes in epidemiology, management, and mortality over the past several decades.
METHODS: We reviewed the data for patients admitted to Bellevue Hospital and New York University Downtown Hospital (New York, New York) over a 10-year period.
RESULTS: Of 79 cases reviewed, 43% occurred in patients with underlying biliary disease. The most common symptoms were fever, chills, and right upper quadrant pain or tenderness. The most common laboratory abnormalities were an elevated white blood cell count (in 68% of cases), temperature >or=38.1 degrees C (90%), a low albumin level (70.2%), and an elevated alkaline phosphatase level (67%). Seventy percent of the abscesses were in the right lobe, and 77% were solitary. Klebsiella pneumoniae was identified in 41% of cases in which a pathogen was recovered. Eighteen (50%) of 36 Asian patients had K. pneumoniae isolated, in contrast to 6 (27.3%) of 22 non-Asian patients (not statistically significant). Fifty-six percent of cases involved treatment with percutaneous drainage. Although prior reports noted mortality of 11%-31%, we observed only 2 deaths (mortality, 2.5%).
CONCLUSIONS: The data suggest that K. pneumoniae has become the predominant etiology of pyogenic liver abscess and that mortality from this disease has decreased substantially.
Abstract/Text
Although rare, pyogenic liver abscesses are potentially fatal. We evaluated the predictive value of Gram stain of liver abscess aspirates and temporally associated blood cultures. Gram stains detected bacteria in 79% of the liver abscesses tested. The sensitivity and specificity of Gram stain of the liver abscesses were 90% and 100% for Gram-positive cocci (GPC) and 52% and 94% for Gram-negative bacilli (GNB). The sensitivities of the blood cultures for any GPC and GNB present in the liver abscess were 30% and 39%, respectively. Although, Gram stains and blood cultures offer incomplete detection of the microbial contents of pyogenic liver abscesses, both tests should always accompany liver abscess cultures.
Hyun Ah Kim, Doo Ryeon Chung, Joon-Sup Yeom, Hyun Kyun Ki, Hae Suk Cheong, Jun Seong Son, Jin Seo Lee, Soo-Youn Moon, Seung Soon Lee, Jeong-A Lee, Kyung-Hwa Park, Seung-Ji Kang, Sook-In Jung, Shin-Woo Kim, Hyun Ha Chang, Seong Yeol Ryu, Ki Tae Kwon, Chisook Moon, Yu Mi Wi, Sang Taek Heo, Mi Kyong Joung, Cheol-In Kang, Kyong Ran Peck, Jae-Hoon Song
Anti-anaerobic coverage is not necessary for Klebsiella pneumoniae liver abscess: a propensity score-matched cohort study.
Diagn Microbiol Infect Dis. 2015 Jan;81(1):60-5. doi: 10.1016/j.diagmicrobio.2014.10.002. Epub 2014 Oct 13.
Abstract/Text
Although most Klebsiella pneumoniae liver abscesses have been reported to be monomicrobial, clinical outcomes have not been compared between antimicrobial therapy with and without anti-anaerobic coverage. A propensity score-matched cohort study was conducted using the 731 cases of K. pneumoniae liver abscess. Clinical outcomes were compared between a group discontinuing anti-anaerobic agents after K. pneumoniae identification and a group continuing. A total of 170 cases were matched at a 1:1 ratio using their propensity to discontinue anti-anaerobic agents. The McNemar's test showed no difference in mortality rates (1.8% for discontinuation versus 2.3% for continuation; P = 1.00) or relapse (1.8% versus 2.9%; P = 0.73) between groups. Early discontinuation of anti-anaerobic agents had no association with treatment failure by means of the generalized estimating equation model (odds ratio 0.48; P = 0.14) and the Kaplan-Meier method (P = 0.85) in matched groups. Early discontinuation of anti-anaerobic agents does not affect the clinical outcomes of patients with K. pneumoniae liver abscess.
Copyright © 2015 Elsevier Inc. All rights reserved.
Abstract/Text
BACKGROUND: Amebic liver abscess (ALA) is a common and serious problem in our country. There are only a few controlled trials on the efficacy and advantages of combination therapy with percutaneous needle aspiration and pharmacotherapy, over pharmacotherapy alone for amebic liver abscess.
MATERIAL AND METHODS: This study was conducted to compare the efficacy of two different treatment modalities i.e. drug treatment alone vs. drug treatment and aspiration of abscess cavity in patients with small (up to 5 cm) and large (5 cm to 10 cm) size ALA. This is one of the largest single center, prospective, randomized studies comparing the efficacy of aspiration in ALA.
RESULTS: (i) Mean body temperature, liver tenderness, total leukocyte count (TLC), serum alanine aminotransferase (ALT) and liver span were significantly decreased in the aspiration group on days 8 and 15 as compared to non-aspiration group especially in large abscess (5 cm to 10 cm). (ii) Abscess cavity maximum diameter decreased significantly in aspiration group on days 8 and 15, and 1 month & 3 months in large abscess (5cm to 10 cm).
CONCLUSIONS: (i) Needle aspiration along with metronidazole hastens clinical improvement especially in large (5 cm up to 10 cm) cavities in patients with ALA. (ii) Aspiration is safe and no major complications occurred. (iii) Hence, combination therapy should be the first choice especially in large ALA (5 cm to 10 cm).
Abstract/Text
OBJECTIVE: This study was designed to determine and compare the efficacy of sonographically guided percutaneous needle aspiration and percutaneous catheter drainage in the treatment of liver abscesses.
SUBJECTS AND METHODS: In a randomized study, 50 patients (38 males and 12 females; age range, 2-72 years; average age, 35 years) with liver abscesses (amebic, 20; pyogenic, 11; indeterminate, 19) underwent either percutaneous needle aspiration (n = 25) or catheter drainage (n = 25) along with appropriate antimicrobial therapy. In patients assigned to the needle aspiration group, an 18-gauge needle was used to aspirate the abscess cavity. Repeated aspiration was attempted only once in each patient not responding to the first aspiration; nonresponse to the second aspiration was considered failure of treatment, and these patients were given catheter drainage (however, these patients were not included in the catheter drainage group). For catheter drainage, 8- to 12-French catheters were introduced into the abscess cavity using the Seldinger technique. In patients with multiple abscesses (seven in aspiration group and five in catheter group), all the abscesses except those smaller than 3 cm were subjected to percutaneous treatment. Patients were followed up to assess the outcome of the percutaneous treatment, length of hospital stay, and development of any complications. Sonography was performed every third day during hospitalization. After discharge of the patient, periodic clinical and sonographic examinations were done until total resolution of abscesses was achieved.
RESULTS: Although percutaneous needle aspiration was successful in only 15 (60%) of the 25 patients after one (n = 11) or two (n = 4) aspirations, catheter drainage was curative in all 25 patients (100%) (p < .05). Among the successfully treated patients, the average time for clinical improvement and the mean hospital stay were similar in the two treatment groups. Although the average time needed for a 50% reduction in the size of the abscess cavity was significantly (p < .05) greater in the aspiration group than in the catheter group (11 days versus 5 days), the average time taken for total resolution of abscess was the same (15 weeks) in both groups. No major complications were encountered. No relapse was documented on clinical and sonographic examination during follow-up, which ranged from 8 to 37 weeks.
CONCLUSION: Our results show that percutaneous catheter drainage is more effective than needle aspiration in the treatment of liver abscesses. Needle aspiration, if limited to two attempts, has a high failure rate.
Abstract/Text
This study aims to compare the therapeutic effectiveness of continuous catheter drainage versus intermittent needle aspiration in the percutaneous treatment of pyogenic liver abscesses. Over a 5-year period, 64 consecutive patients with pyogenic liver abscess were treated with intravenous antibiotics (ampicillin, cefuroxime, and metronidazole) and randomized into two percutaneous treatment groups: continuous catheter drainage (with an 8F multi-sidehole pigtail catheter); and intermittent needle aspiration (18G disposable trocar needle). There was no statistically significant difference between the two groups regarding patient demographics, underlying coexisting disease, abscess size, abscess number, number of loculation of abscess, the presenting clinical symptoms such as fever, abdominal pain, and pretreatment liver function test. Although not statistically significant, the duration of intravenous antibiotics treatment before percutaneous treatment was longer with the catheter group, and the change of antibiotics after the sensitivity test was more frequent with the needle group. The needle group was associated with a higher treatment success rate, a shorter duration of hospital stay, and a lower mortality rate, although this did not reach statistical significance. In conclusion, this study suggests that intermittent needle aspiration is probably as effective as continuous catheter drainage for the treatment of pyogenic liver abscess, although further proof with a large-scale study is necessary. Due to the additional advantages of procedure simplicity, patient comfort, and reduced price, needle aspiration deserves to be considered as a first-line drainage approach.
Abstract/Text
BACKGROUND: Metronidazole is the standard of care for uncomplicated amoebic liver abscesses (considering that complicated liver abscesses are those localized in left lobe, multiple, and/or pyogenic abscesses). However, a subset of patients with amoebic liver abscesses remain symptomatic, with a significant risk of rupture of the abscess into the peritoneum. The role of image-guided percutaneous therapeutic aspiration in these patients remains controversial.
OBJECTIVES: To assess the beneficial and harmful effects of image-guided percutaneous procedure plus metronidazole versus metronidazole alone in patients with uncomplicated amoebic liver abscess.
SEARCH STRATEGY: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 2, 2007), MEDLINE (1966 to November 2007), EMBASE (1988 to September 2007), and Science Citation Index Expanded (1945 to September 2007).
SELECTION CRITERIA: Randomised or quasi-randomised trials comparing an image-guided percutaneous procedure plus metronidazole versus metronidazole alone in patients with uncomplicated amoebic liver abscess.
DATA COLLECTION AND ANALYSIS: Inclusion criteria, trial quality assessment, and data extraction were done in duplicate. We calculated relative risks (RR) and mean differences, and checked for heterogeneity by visual inspection of forest plots and chi-squared and I(2) tests.
MAIN RESULTS: Seven low quality randomised trials were included. All studies included a total of 310 patients, but due to selective outcome reporting bias, less patients could be included in our analyses. Pooled analysis of three homogenous trials showed that needle aspiration did not significantly increase the proportion of patients with fever resolution (RR 0.60, 95% confidence interval (CI) 0.22 to 1.61). Sensitivity analysis according to trial quality preserved these findings. Trials that evaluated resolution of abdominal pain, days to resolution of fever, pain, resolution of abscess cavities, reduction in liver size, and duration of hospitalisation were heterogeneous. The benefits in the number of days to resolution of pain (MD -1.59, 95%CI -2.73 to -0.42), number of days to resolution of abdominal tenderness (MD -1.70, 95%CI -2.86 to -0.54), and duration of hospitalisation (MD -1.31, 95%CI -2.05 to -0.57) were observed in the needle aspiration group only.
AUTHORS' CONCLUSIONS: Therapeutic aspiration in addition to metronidazole to hasten clinical or radiologic resolution of uncomplicated amoebic liver abscesses cannot be supported or refuted by the present evidence. The trials lack methodological rigour and adequate sample size to conclude on the presence of effectiveness of adjunctive image-guided aspiration plus metronidazole versus metronidazole alone. Further randomised trials are necessary.
