Management of Liver Abscess

 CAUSATIVE AGENTS

• Enterobacteriaceae (E. coli, Klebsiella pneumoniae) S. milleri Enterococcus spp S. aureus Anaerobes (Bacteroides spp, Fusobacterium spp, Actinomyces spp, Clostridium spp) Entamoeba histolytica

EMPIRIC TREATMENT

• Empiric coverage should include Enterobacteriaceae,enterococci, anaerobes, and in certain situations staphylococci and streptococci. 
• In a stable patient antibiotics may be deferred until post -aspiration/drainage to increase culture yield.
• Consider empiric antifungal treatment in immunosuppressed patients at risk for chronic disseminated candidiasis
• Culture results may help narrow coverage, but for pyogenic abscess do not discontinue anaerobic coverage given difficulty culturing these organisms
• Ampicillin 2.0g IV q6h plus gentamicin 1.7mg/kg IV q8h plus metronidazole 0.5g IV q8h
• Cefotaxime 2.0g IV q8h or ceftriaxone 2.0g IV q24h plus metronidazole 0.5g IV q8h
• Piperacillin/tazobactam 3.375g IV q 6h. Consider adding metronidazole if amebic liver abscess a possibility.
• Carbapenems: appropriate for monotherapy, especially if the patient is at high risk for resistant GNRs or has a documented multidrug-resistant organism.
• Fluroquinolones: often used as an oral regimen for prolonged therapy after completion of initial parenteral therapy course.

Guide to Adult Antimicrobial Therapy in ICU 2012

Selection factors for choice of antibiotics

Johns Hopkins ABX Guide

DURATION

• Often 14-42 days total, if adequate drainage achieved with resolution of fever and leukocytosis
• Longer courses (up to several months) may be required in the patient who is inadequately drained or treated without drainage
• In some guides, Pyogenic liver abscess will require 4-6 weeks wherelse Amoebic liver abscess will require 7-10 followed by a luminal agent for eradication of gut colonisation (Malaysian ICU Antibiotic Guideline)

REFERENCES:

1. Hepatic Abscess. http://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540259/all/Hepatic_Abscess
2. Guide to Antimicrobial Therapy in Adult ICU 2012
3. NAG 2008