AIIMS releases guidance on Antibiotics in Liver Abscess

All India Institute of Medical Sciences, Delhi has released AIIMS Antibiotics Policy which has been prepared by the Department of Medicine with Multidisciplinary collaboration. The guidance for Gastroenterological Infections includes Antibiotics in Liver Abscess the salient features of which have been authored in the guidance.

When to suspect:

• 
  

  Fever with/without chills, constitutional symptoms

  
  


• 
  

  Right upper quadrant tenderness

  
  


• 
  

  Intercostal tenderness can be present

  
  


• 
  

  Right shoulder pain

  
  


• 
  

  Hepatomegaly

  
  


• 
  

  Diarrhoea- present in 23% of patients of amoebic liver abscess

  
  


• 
  

  Nausea, vomiting

  
  


• 
  

  Right pleural effusion and cough-30% of patients

  
  


• 
  

  Ascites, Jaundice-26% of patients

  
  


• 
  

  Leukocytosis with raised liver enzymes (AST, ALT, ALP)

  
  

How to confirm:

• 
  

  Blood Culture- Positive in 50% of patients

  
  


• 
  

  USG- Variable echogenic lesion (Sensitivity- 86-90%)

  
  


• 
  

  CT- Hypodense lesion (Sensitivity>95%)

  
  


• 
  

  Gram stain and bacterial culture of aspirate

  
  


• 
  

  Serum amoebic serology- may remain positive years after infection.

  
  


• 
  

  E. histolytica antigen- Serum, stool and aspirate

  
  

1. 
   

   Pyogenic Liver Abscess

   
   

Aetiology:

Gram-negative aerobes: E coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter, Citrobacter

Gram-positive aerobes: Staphylococcus aureus, Streptococcus, Enterococcus

Gram-negative anaerobes: Bacteroides, Fusobacterium

Gram-positive anaerobes: Clostridium

Treatment:

Inpatient: [Ceftriaxone 1g IV BD plus Metronidazole 500 mg IV TDS] OR [Amoxicillin-clavulanate 1.2g IV TDS]

Outpatient: [Amoxicillin-clavulanate 625mg TDS] OR [Cefixime 200mg BD Plus Metronidazole 400 mg TDS]

Special Considerations:

Hemodynamic instability/ Multi-organ involvement/Suspected ESBL producer:

Piperacillin+ Tazobactam 4.5 g IV QID or Cefoperazone+ Sulbactam 2 -3 gm IV BD or Imipenem+ Cilastatin 500mg IV QID or Meropenem 1-2g IV TDS

High suspicion of Gram-positive agent- MRSA or resistant Enterococcus: Additional Vancomycin 1g IV BD

2. 
   

   Amoebic Liver Abscess: E histolytica (72% serology positive)

   
   

IV: Metronidazole 750 mg IV TDS for 7-10 days

Oral: Tab Metronidazole 800 mg PO TDS for 7-10 days or Tinidazole 2 g OD for 3-5 days

Luminal Amoebicides: After a response to initial therapy; Diloxanide furoate 500mg TDS orally for 10 days.

1. 
   

   Percutaneous drainage: Often useful as an adjunct with antibiotics

   
   

• 
  

  Left lobe abscess

  
  


• 
  

  High risk of rupture / sub-capsular location

  
  


• 
  

  Ruptured liver abscess

  
  


• 
  

  Size > 5cm

  
  


• 
  

  No response to antibiotic

  
  


• 
  

  Unclear diagnosis/ negative workup

  
  


• 
  

  Multiple aspirations may be required in case of re-accumulation.

  
  

2. 
   

   Endoscopic drainage: In case of abscess communication with the biliary tree, ERCP and sphincterotomy and drainage can be done.

   
   


3. 
   

   Surgical drainage- (open or laparoscopic procedure):

   
   

• Large multiloculated abscess >5cm in size

• Abscess rupture with peritonitis

• Failed percutaneous drainage and antibiotic therapy

Special Remarks:

If the etiological diagnosis of liver abscess is not made, empiric coverage should cover both pyogenic and amoebic liver abscess. In such a situation, if antibiotics with anaerobic cover (amoxicillin-clavulanate, piperacillin – Tazobactam, cefoperazone- sulbactam, imipenem or meropenem) are used concurrently with metronidazole, the latter may be stopped after 7-10 days.