Liver abscess

There is this Indian uncle who had admitted to my ward complaining of fever for 3 days and worsening abdominal pain for 1 week. Patient is an alcoholic. Initially he was suspected to have acute calculus cholecystitis and meliodosis. However, CT scan showed that he actually had liver abscess. (a pus filled cavity in the liver).

His blood culture and sensitivity taken on admission showed present of Enterobacter Sakazakii. As there is multiple loculi, and the size of each of the loculus was small, there is no indication for surgical drainage of the abscess. Therefore the surgeons plan to start on conservative management, which is starting antbiotics treatment. So, for how long should we give the antibiotics???

There are 3 types of liver abscess, namely pyogenic, amebic and also fungal liver abscess. In this article, lets discuss pyogenic and amebic liver abscess. Pyogenic abscess is usually present as multiple loculi on the CT scan and commonly cause by gram negative enteric organism such as Klebsiella pneumonia, Enterobacteriacae, enterococcus, anaerobics. On the other hand, amebic liver abscess is usually present as single loculus caused by parasite Entamoeba histolytica. The antibiotics required for this 2 types are different.

Patient in this case received antibiotics (IV cefoperazone 1g BD and IV metronidazole) for 5 days and later discharge with Tab cefuroxime 250mg BD and Tab metronidazole 400mg TDS for 6 weeks. The careless houseman in charge only prescribed 1 week antibiotics for him. Luckily the error was later amended after being informed by us. (this HO did not even show a slight appreciation!!!!! OMG, seriously beh tahan with her "DO I CARE" face. Can't she just say THANK YOU???)

Come back to the case, the national antibiotics guidline in Malaysia back in 2008 is not clear... The guideline only mentioned that patient should be treated until clinical improvement achieved. In pyogenic liver abscess, the choice of IV antibiotics include:
IV Ampicilin + IV Metronidazole + IV Gentamicin, x 2 weeks (Effective but resistant toward ampicilin increased and Gentamicin may cause nephrotoxicitiy)
or
IV Ampicillin/sulbactam alone x 2 weeks. (metronidazole may be added if cant rule out amebic)

Then, the alternative agents include:
IV 3rd gen cephalosporin + IV Metronidazole x 2 weeks or
IV ciprofloxacin + IV Metronidazole x 2 weeks.

For amoebic liver abscess, IV metronidzole 500mg TDS may be started for 10 days and Tab Tinidzole 2g OD for 3-5 days.

Then from Sanford guideline, pyogenic liver abscess may be treated with:
IV metronidazole + (IV ceftriazone or IV ciprofloxacin or IV Pip/Tazo or IV Amp/Sulbactam)
and amebic liver abscess with metronidazole, however the duration was not mentioned.

A search on the total duration of antibiotics patient should received is unclear and inconclusive. The suggested duration include IV antibiotics for 2 to 3 weeks followed by oral anitbiotics for 3 to 12 weeks. The common practice in Hospital Selayang as informed by one of the doctor is IV antibiotics for 2 weeks followed by 6 weeks oral antibiotics.

In the Malaysia ICU antibiotic guideline, pyogenic liver abscess required 6 weeks of oral antibiotics while amebic liver abscess only require 7 to 10 days of therapy followed by a luminal agent for gut colonisation. Suggested regimen for those who is hemodynamically unstable are:
IV Pip/Tazo + IV metronidazole  ---- prefered
IV Cefepime + IV metronidazole ---- prefered
IV Meropenem + IV metronidazole ---- alternative
IV Imipenem/Cilastatin + IV metronidazole ---- alternative

Then for those who is hemodynamically stable are:
IV Ceftriaxone + IV metronidazole
IV Pip/Tazo + IV metronidazole

The SD number for patient is SD330816 for future reference.