Liver Abscess Medication

  • Author: Ruben Peralta, MD, FACS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Nov 30, 2011
 

Medication Summary

Until cultures are available, the choice of antimicrobial agents should be directed toward the most commonly involved pathogens. Regimens using beta-lactam/beta-lactamase inhibitor combinations, carbapenems, or second-generation cephalosporins with anaerobic coverage are excellent empiric choices for the coverage of enteric bacilli and anaerobes. Metronidazole or clindamycin should be added for the coverage of Bacteroides fragilis if other employed antibiotics offer no anaerobic coverage.

Amebic abscess should be treated with metronidazole, which will be curative in 90% of cases. Metronidazole should be initiated before serologic test results are available. Patients who do not respond to metronidazole should receive chloroquine alone or in combination with emetine or dehydroemetine.

Systemic antifungal agents should be initiated if fungal abscess is suspected and after the abscess has been drained percutaneously or surgically. Initial therapy for fungal abscess is currently amphotericin B. Lipid formulations may offer some benefit in that the complexing of drug to lipid moieties allows for concentration in hepatocytes. Further investigation is required for definitive proof. Cases of successful fluconazole treatment after amphotericin failure have been reported; however, its use as an initial agent is still being studied.

Ultimately, the organisms isolated and antibiotic sensitivities should guide the final choice of antimicrobials.

Duration of treatment has always been debated. Short courses (2 wk) of therapy after percutaneous drainage have been successful in a small series of patients; however, most series have reported recurrence of abscess even after more prolonged courses. Currently 4-6 weeks of therapy is recommended for solitary lesions that have been adequately drained. Multiple abscesses are more problematic and can require up to 12 weeks of therapy. Both the clinical and radiographic progress of the patient should guide the length of therapy.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

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Meropenem (Merrem)

 

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Has slightly increased activity against gram negatives and slightly decreased activity against staphylococci and streptococci species compared to imipenem.

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Imipenem and cilastatin (Primaxin)

 

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.

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Cefuroxime (Ceftin)

 

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.

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Cefotetan (Cefotan)

 

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism.

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Cefoxitin (Mefoxin)

 

Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

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Cefaclor (Ceclor)

 

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

Determine proper dosage and route based on condition of patient, severity of infection, and susceptibility of causative organism.

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Clindamycin (Cleocin)

 

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.

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Metronidazole (Flagyl)

 

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

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Antifungal agents

Class Summary

Their mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

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Amphotericin B (AmBisome)

 

Produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal-cell membrane, causing intracellular components to leak with subsequent fungal-cell death.

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Fluconazole (Diflucan)

 

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.

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Contributor Information and Disclosures
Author

Ruben Peralta, MD, FACS  Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic

Ruben Peralta, MD, FACS is a member of the following medical societies: American Association of Blood Banks, American College of Healthcare Executives, American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, and Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle V Lisgaris  MD, Assistant Professor, School of Medicine, Case Western Reserve University

Michelle V Lisgaris is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Robert A Salata, MD  Chief and Clinical Program Director of Division of Infectious Diseases, Vice Chair for International Affairs, Professor, Department of Medicine, Case Western Reserve University School of Medicine

Robert A Salata, MD is a member of the following medical societies: American Association of Immunologists, American Federation for Medical Research, American Medical Association, Central Society for Clinical Research, Infectious Diseases Society of America, Ohio State Medical Association, and Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Marco G Patti, MD  Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA  Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

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Table 1: Presenting symptoms and signs in 715 patients diagnosed with liver abscess.
Table 2: Microbiologic results from 312 cases of liver abscess compiled from the literature.
Table 3: Comparison of the radiologic procedures used in the diagnosis of liver abscess.
Table 4: Underlying etiology of 1086 cases of liver abscess compiled from the literature.
Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.
Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.
 
 
 
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