Hepatic Abscess

Christopher F. Carpenter, M.D., Nick Gilpin, D.O.

PATHOGENS
 Gram-positive cocci: Streptococcus species (especially S. intermedius group), enterococci,
andStaphylococcus aureus.
 Anaerobes: Bacteroides species, Fusobacterium sp, Actinomyces sp, Clostridium sp, etc.
 Enterobacteriaceae (E. coli, Klebsiella spp., etc) and other Gram-negative bacilli.
 Yersinia enterocolitica: rare cause of liver abscess; if identified, consider underlying
hemochromatosis.
 Candida species
 Entamoeba histolytica: amebic liver abscesses may complicate up to 10% of the cases of amebic
colitis.
 Echinococcus granulosus: most common cause of hydatid cysts.

CLINICAL
 Risk factors for development of hepatic abscess include:
o Diabetes
o Liver cirrhosis
o Immunocompromised state
o Male sex
o Advanced age
o 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
o
malaise.
o Presentation may be subacute or chronic including weight loss, anorexia.
o Occasionally, patients may be acutely ill with mental status changes.
o Rarely, patients may present with sepsis and peritoneal signs from intraperitoneal rupture of
the abscess.
 Approximately 50% of patients have a solitary hepatic abscess.
o Majority of abscesses involve in the right hepatic lobe (~75%), less commonly left (20%) or
caudate (5%) lobes.
o Diaphragmatic irritation from abscess might refer pain to the right shoulder or result in cough
or pleural rub.
 Classified by presumed origin:
o 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.
o Parasitic: 

 Entamoeba histolytica: abscess occurs via the portal system during amebic colitis.
o Typically manifests as a right lobe solitary lesion.
o 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.
o 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).
o Rarely seen in the U.S.; generally infections diagnosed in immigrants with late
presentation or by incidental identification.
o 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.
o Increased mortality reported in polymicrobial and fungal infections, and in
immunocompromised patients.

DIAGNOSIS
 Labs:
o 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:
o Plain abdominal radiography: dx may be suggested on plain films (e.g., gas within the
abscess)
o Preferred: CT, US and MRI are the imaging modalities of choice in suspected liver abscess
orFUO.
o 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:
o Positive amebic or echinococcal serology helps differentiate parasitic liver abscess from
pyogenic, especially in nonendemic areas. Serology cannot distinguish between active and
prior infection.
o 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.
o Aspirate should be sent for Gram stain and aerobic/anaerobic culture.
o 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:
o Success in up to 90% of cases.
o If drainage inadequate, surgical drainage may be required.
o 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).
o 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.
o Complex or ruptured abscess
o Multiple abscesses
o Percutaneously unreachable abscess
o Larger abscesses (> 5 cm)
o If associated surgical problem also present (e.g., peritonitis)
o 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

o
culture yield.
o Consider empiric antifungal treatment in immunosuppressed patients at risk for chronic
disseminated candidiasis (CDC, a.k.a. hepatosplenic candidiasis, also see C.
albicansmodule).
o 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.
 oTraditional: ampicillin 2.0g IV q6h plus gentamicin 1.7mg/kg IV q8h
plus metronidazole 0.5g IV q8h
o First line:
 Cefotaxime 2.0g IV q8h or ceftriaxone 2.0g IV q24h plus metronidazole 0.5g IV q8h
 Piperacillin/tazobactam 3.375g IV q 6h
o Consider adding metronidazole if amebic liver abscess a possibility.
 Alternatives:
o Carbapenems: appropriate for monotherapy, especially if the patient is at high risk for
resistant GNRs or has a documented multidrug-resistant organism.
 Ertapenem
 Imipenem
 Meropenem
 Doripenem
o Fluoroquinolones: often used as an oral regimen for prolonged therapy after completion of
initial parenteral therapy course.

Ciprofloxacin, levofloxacin or moxifloxacin plus metronidazole
 Duration: if adequate drainage achieved with resolution of fever and leukocytosis.

o Often 14-42 days total.

o Longer courses (up to several months) may be required in the patient who is inadequately
drained or treated without drainage.
o 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

o
luminal agent to eliminate residual colonic colonization, usually paromomycin 500mg three
times a day PO x 7d.
 Alternatives:
o Tissue agent: tinidazole 800mg three times a day or 2g +daily x 3-5d.
o Luminal agents: 

 Iodoquinol 650mg three times a day x 20d

 Diloxanide furoate 500mg three times a day x 10d
 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.
 o 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.
o Hyperamylasemia and eosinophilia occur in up to 60%.
 Surgical resection standard intervention:
o 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.
o 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; lacksPseudomonas 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 Broad spectrum coverage including Gram-positive coverage,
Acid 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 condit ions (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

Pathogen First-Line Agent Second-Line Agent
Anaerobes Metronidazole Piperacillin/tazobactam, ticarcillin/clavulanic
acid,ampicillin/sulbactam, imipenem/cilistatin, meropenem,doripenem, 
ertapenem, tigecycline, clindamycin
Enterococci Penicillin orampicillin  Vancomycin +/- gentamicin, linezolid, daptomycin, tigecycline
+/-gentamicin
 Staphylococ MSSA: Vancomycin, linezolid, daptomycin, tigecycline
cus aureus Nafcillin oroxacillin,c
efazolin
MRSA:
Vancomycin
Coagulase Vancomycin Daptomycin, linezolid, tigecycline
negative
staphylococ
ci
Streptococc Penicillin orampicillin First-, second-, or third-generation cephalosporins
i
Pseudomon Piperacillin,cefepime, Imipenem, meropenem, doripenem, ciprofloxacin,
as ceftazidime, Piperacillin/tazobactam
aeruginosa
Entamoeba Metronidazolefollowe Tinidazole (in place of metronidazole) followed by iodoquinol,
histolytica( d byparomomycin or diloxanide furoate in place of paromomycin;
amebic
liver
abscess)
Candida Amphotericin B Lipid formulations of amphotericin
albicansor Fluconazole B, voriconazole,caspofungin, anidulafungin, micafungin
other Candi
da species
Echinococc Surgical resection or Albendazole
us species PAIR procedure

Basis for recommendation

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