PATHOGENS

CLINICAL

  • Risk factors for development of hepatic abscess include:
    • Diabetes
    • Liver cirrhosis
    • Immunocompromised state
    • Male sex
    • Advanced age
    • Proton-pump inhibitor use
  • Signs and symptoms: include fever +/- RUQ pain, tenderness w/ hepatomegaly.
    • Some may only have nonspecific symptoms such as fever (60%) associated with chills and malaise.
    • Presentation may be subacute or chronic including weight loss, anorexia.
    • Occasionally, patients may be acutely ill with mental status changes.
    • Rarely, patients may present with sepsis and peritoneal signs from intraperitoneal rupture of the abscess.
  • Approximately 50% of patients have a solitary hepatic abscess.
    • Majority of abscesses involve in the right hepatic lobe (~75%), less commonly left (20%) or caudate (5%) lobes.
    • Diaphragmatic irritation from abscess might refer pain to the right shoulder or result in cough or pleural rub.
  • Classified by presumed origin:
    • Bacterial:
      • Up to 50% develop from biliary tract (cholangitis).
      • Remainder are from hepatic artery (bacteremia), portal vein (abdominal source, e.g. diverticulitis), contiguous focus (local abscess or cholecystitis) or penetrating trauma.
      • Many are of cryptogenic origin.
    • Parasitic:
      • Entamoeba histolytica: abscess occurs via the portal system during amebic colitis.
        • Typically manifests as a right lobe solitary lesion.
        • Rare in most locales in U.S., occurring almost exclusively in immigrants (especially South and Central America) and travelers so more common in such regions such as southern California, Texas, etc.
        • Men, especially MSM, at higher risk for invasive disease.
      • Echinococcal (hydatid) cysts: most commonly caused by Echinococcus granulosus and usually acquired from canines (sheep dogs).
        • Rarely seen in the U.S.; generally infections diagnosed in immigrants with late presentation or by incidental identification.
        • Usually asymptomatic; when symptoms develop they are due to the size of enlarging cyst or leakage/rupture.
  • Underlying disease typically is the primary determinant of outcome of hepatic abscess.
    • Increased mortality reported in polymicrobial and fungal infections, and in immunocompromised patients.

DIAGNOSIS

  • Labs:
    • For pyogenic liver abscess(es), positive blood cultures seen in up to 50%; alkaline phosphatase and WBC counts frequently elevated.
      • Hyperbilirubinemia with or without jaundice occurs in < 50% of patients.
  • Imaging:
    • Plain abdominal radiography: dx may be suggested on plain films (e.g., gas within the abscess)
    • Preferred: CT, US and MRI are the imaging modalities of choice in suspected liver abscess or FUO.
    • CT or US-guided percutaneous drainage or surgical drainage should be considered in all cases of hepatic abscess for diagnostic confirmation and culture.
      • Multiple, small abscesses may not be amendable to aspiration.
  • Serology:
    • Positive amebic or echinococcal serology helps differentiate parasitic liver abscess from pyogenic, especially in nonendemic areas. Serology cannot distinguish between active and prior infection.
    • Uncomplicated, small abscesses due to Entamoeba histolytica in endemic areas may not require aspiration; consider empirical rx.

TREATMENT

Drainage and General Management

  • Abscess drainage is the optimal therapy for pyogenic liver abscesses.
    • Aspirate should be sent for Gram stain and aerobic/anaerobic culture.
    • Evaluation for fungal and mycobacterial pathogens. E. histolytica should be considered based on epidemiologic factors.
  • CT- or US-guided percutaneous needle aspiration +/- catheter drainage initial method of choice:
    • Success in up to 90% of cases.
    • If drainage inadequate, surgical drainage may be required.
    • Percutaneous aspiration without catheter placement: recently found to have similar success rates as catheter placement.
      • Repeat aspiration required in approximately 50%.
      • Catheter placement should be considered in larger abscesses (>5 cm diameter).
    • Complications of percutaneous drainage include: perforation of adjacent abdominal organs, pneumothorax, hemorrhage and leakage of abscess contents in peritoneum.
  • General recommendations are for at least one week of drainage with CT follow-up.
  • Surgical drainage: may consider as primary treatment in certain settings.
    • Complex or ruptured abscess
    • Multiple abscesses
    • Percutaneously unreachable abscess
    • Larger abscesses (> 5 cm)
    • If associated surgical problem also present (e.g., peritonitis)
    • Drainage may be done laparoscopically
  • Hepatotomy: generally successful approach, but improvements in percutaneous techniques make it secondary management in most cases.
  • Medical management: consider in patients at high risk for drainage procedures or with small/multiple abscesses (< 3-5 cm in diameter) not amenable to drainage.

Antibiotic 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 (CDC, a.k.a. hepatosplenic candidiasis, also see C. albicans module).
    • Culture results may help narrow coverage, but for pyogenic abscess do not discontinue anaerobic coverage given difficulty culturing these organisms.
  • Empiric regimens: may narrow based on culture results.
  • Alternatives:
  • Duration: if adequate drainage achieved with resolution of fever and leukocytosis.
    • Often 14-42 days total.
    • Longer courses (up to several months) may be required in the patient who is inadequately drained or treated without drainage.
    • Follow-up imaging studies: consider in patients with suboptimal clinical response.
      • Use CT or ultrasound.
      • Note: imaging findings may lag behind other markers of clinical response.

Amebic hepatic abscess

  • See Entamoeba histolytica module for additional details.
  • Preferred:
    • Metronidazole 750mg PO three times a day x 7-10 days as a tissue agent, followed by a luminal agent to eliminate residual colonic colonization, usually paromomycin 500mg three times a day PO x 7d.
  • Alternatives:
    • Tissue agent: tinidazole 800mg three times a day or 2g +daily x 3-5d.
  • Percutaneous aspiration has no clear role in therapy, but consider for diagnosis if uncertain (serology inconclusive or not available) or no response to appropriate antibacterial therapy.
    • Predictors of need for aspiration: include age> 55 years, abscesses > 5 cms, involvement of both lobes of liver and failure of medical therapy after 7 days.

Hydatid (Echinococcal) cyst

  • Most commonly E. granulosus, see module for additional details.
  • Serology helpful in most cases in non-endemic areas.
  • In patients with rupture of the cyst into the biliary tree, transient but markedly elevated levels of alkaline phosphatase and bilirubin may occur.
    • Hyperamylasemia and eosinophilia occur in up to 60%.
  • Surgical resection standard intervention:
    • Uncomplicated cysts: PAIR (Percutaneous puncture with CT or US guidance, followed by Aspiration, Injection of a protoscolicidal agent such as hypertonic saline or ethanol, and finally Re-aspiration 15 minutes later) is becoming more accepted treatment of choice at some centers due to high success rates with low morbidity.
    • Open or percutaneous (PAIR) procedures should be combined with albendazole treatment.

Selected Drug Comments

Drug

Recommendation

Ampicillin/sulbactam

Good coverage of Gram-positive, Gram-negative, and anaerobic pathogens; lacks Pseudomonas aeruginosa coverage but good Enterococcus species coverage. Rising rates of resistance in E. coli mean that this is no longer a favored empiric choice, but may be quite acceptable once culture results have returned.

Cefepime

Excellent coverage of Gram-negative w/ some Gram-positive pathogens; use in combination with anaerobic agent for empiric therapy.

Imipenem/cilastatin

Excellent broad-spectrum (Gram-positive, Gram-negative, and anaerobe) coverage; would reserve for seriously ill patients. Has better coverage for E. faecalis than meropenem or doripenem; none of the carbapenems cover E. faecium.

Meropenem

Excellent broad spectrum (Gram-positive, Gram-negative, and anaerobe) coverage; would reserve for seriously ill patients. Will cover E. faecalis; none of the carbapenems cover E. faecium.

Ertapenem

Once-daily carbapenem with excellent broad-spectrum coverage except P. aeruginosa, Acinetobacter spp., and enterococci.

Doripenem

Newer carbapenem approved recently for complicated IAIs. Excellent Gram-positive (except E. faecium), Gram-negative and anaerobic coverage.

Moxifloxacin

Excellent broad-spectrum coverage includes some anaerobic activity, many would still use with metronidazole with liver abscess condition due to resistance among B. fragilis.

Piperacillin/tazobactam

Excellent broad spectrum coverage including Gram-positive and Gram-negative coverage (including Pseudomonas aeruginosa and β-lactamase producing pathogens) and anaerobic coverage.

Ticarcillin/clavulanic Acid

Broad spectrum coverage including Gram-positive coverage, Gram-negative coverage (including Pseudomonas aeruginosa [but less active than piperacillin/tazobactam] and B-lactamase producing pathogens) and anaerobic coverage. No longer available in the U.S. marketplace.

Metronidazole

Remains premier anti-anaerobic drug, and preferred for pyogenic abscesses in combination therapy, also treats amebic liver infection.

Tigecycline

Broad spectrum agent related to minocycline, with excellent gram-positive (including MRSA and VRE), Gram-negative (except Pseudomonas aeruginosa and Proteus mirabilis) and anaerobic activity, approved for complicated intraabdominal infections.

FOLLOW-UP

  • If untreated, mortality rate associated with pyogenic hepatic abscess approaches 100%.
  • With treatment, in some series, mortality is below 15%; the latter mortality is dependent upon underlying disease.
  • Recurrence is more frequent after simple percutaneous aspiration without placement of a temporary drain, or in patients in whom drains are removed too early.

OTHER INFORMATION

  • Hepatic abscesses are frequently polymicrobial.
  • Single/multiple lesions occur in approximately a 1:1 ratio, with the majority in the right lobe (especially when solitary); cryptogenic abscesses are generally solitary.
  • Abscesses are frequently associated with chronic medical conditions (e.g., diabetes), hematologic disease (e.g., leukemia), and chronic granulomatous disease (Staphylococcus aureus).
  • Chronic disseminated candidiasis (CDC, a.k.a. hepatosplenic candidiasis) occurs in immunosuppressed patients, e.g. bone marrow transplant recipients.

Pathogen Specific Therapy

Basis for recommendation

  1. Author opinion

    Comment: Recommendations in this module are based on literature given lack of robust RCT data and guideline statements.

References

  1. Mavilia MG, Molina M, Wu GY: The Evolving Nature of Hepatic Abscess: A Review. J Clin Transl Hepatol 4:158, 2016  [PMID:27350946]

    Comment: Authors divide hepatic abscesses into three categories: infectious, iatrogenic and those associated with malignancy.

  2. Cai YL et al: Percutaneous needle aspiration versus catheter drainage in the management of liver abscess: a systematic review and meta-analysis. HPB (Oxford) 17:195, 2015  [PMID:25209740]

    Comment: Review of five RCTs suggests catheter drainage preferred over simple aspiration as it is correlated with higher success rates, faster resolution of cavity size.

  3. Siu LK et al: Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis 12:881, 2012  [PMID:23099082]

    Comment:
    Provides an overview of clinical features and management of hepatic abscesses caused by Klebsiella.

  4. Nasseri-Moghaddam S et al: Percutaneous needle aspiration, injection, and re-aspiration with or without benzimidazole coverage for uncomplicated hepatic hydatid cysts. Cochrane Database Syst Rev  [PMID:21249654]

    Comment: No RCTs identified to support or refute role of PAIR procedure with or without benzimidazole for hydatid cysts.

  5. Reid-Lombardo KM, Khan S, Sclabas G: Hepatic cysts and liver abscess. Surg Clin North Am 90:679, 2010  [PMID:20637941]

    Comment: Contains a review of pyogenic (including a breakdown of pyogenic causes and microbiology) and parasitic (including hydatid cyst and amoebic) liver abscesses.

  6. Benedetti NJ, Desser TS, Jeffrey RB: Imaging of hepatic infections. Ultrasound Q 24:267, 2008  [PMID:19060716]

    Comment: Review of imaging of hepatic abscesses and other hepatic infections.

  7. Khan R et al: Predictive factors for early aspiration in liver abscess. World J Gastroenterol 14:2089, 2008  [PMID:18395912]

    Comment: Predictive factors for early aspiration in liver abscess

  8. Kurland JE, Brann OS: Pyogenic and amebic liver abscesses. Curr Gastroenterol Rep 6:273, 2004  [PMID:15245694]

    Comment: Review of the most common infectious causes of abscess disease in the liver.
    Rating: Important

  9. Yu SC et al: Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration. Hepatology 39:932, 2004  [PMID:15057896]

    Comment: Compares catheter drainage versus needle aspiration.

  10. Solomkin JS et al: Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis 37:997, 2003  [PMID:14523762]

    Comment: Consensus, evidence-based general guidelines from IDSA, SIS, ASM, and SIDP.

  11. Lambertucci JR et al: Pyogenic abscesses and parasitic diseases. Rev Inst Med Trop Sao Paulo 43:67, 2001 Mar-Apr  [PMID:11340478]

    Comment: Association of underlying parasitic disease and superinfection with bacteria.

  12. Ghosh JK et al: Efficacy of aspiration in amebic liver abscess. Trop Gastroenterol 36:251, 2015 Oct-Dec  [PMID:27509703]

    Comment: Study suggests aspiration for large abscesses (>5-10 cm) plus MTZ hastens resolution and appears to be safe to perform.

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Last updated: October 4, 2017

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