Liver abscess is mostly pyogenic, with Staphylococcus aureus as the most common organism seen in India. Treatment involves drainage of the abscess combined with intravenous antibiotics such as cloxacillin, cefotaxime, and metronidazole for at least 2 weeks, followed by 6 weeks of oral antibiotics. The choice of antibiotics may be modified based on culture and sensitivity results. Amebic liver abscess is usually treated with intravenous metronidazole for 7 days followed by an oral luminal amebicidal drug like diloxanide furoate for 10 days.

1. Antibiotics in Liver abscess
Dr.Vishnu Biradar
Pediatric Gastroenterologist
DMH and ABMH, Pune
Maharashtra

2. Outline
• Epidemiology
• Types of liver abscess
• Antibiotic in PLA
• Causative organisms
• Choice
• Duration
• Resistance pattern
• Antibiotics in ALA
• Other treatment options

3. Epidemiology
• Incidence of Pyogenic liver abscess
– 1 in 140 admissions in Brazil
• Ferreira MA, Pereira FE, Musso C, Dettogni RV. Pyogenic liver abscess in
children: some observations in the Espírito Santo State, Brazil. Arq
Gastroenterol 1997;34:49-54
– More than 79 per 100,000 pediatric admissions in
India
• Kumar A, Srinivasan S, Sharma AK. Pyogenic liver abscess in
children―South Indian experiences. J Pediatr Surg 1998;33:417-421
• Incidence of Amoebic liver abscess
– No data

4. Different types of LA
Pyogenic Amoebic Fungal Parasitic
% 80 10-20 5-8 <1
Most common Not uncommon Rare Very rare

5. Recommended Antibiotics in PLA
• Broad spectrum antibiotics which includes
– Ampicillin
– Aminoglycoside or Third generation cephalosporins
– Metronidazole
• Alternative regimen
– Beta lactam and beta lactamase inhibitor

6. Why ?
• What are common organisms ?
• India ?
• Then what should be our choice?

7. Organisms in PLA in World
Country /
Organisms
France
(1985-2003)
Culture Positive 8/16 43/82
coliforms 49%
Klebsiella spp 1 10 cases
E coli 1 8 cases
mixed coliforms 3 cases
Streptococcus milleri 6 cases
Pseudomonas 4 cases
Staphylococcus aureus 5 2 cases
CONS 1 2 cases
Anaerobes 2 cases
Tb 2 cases
Positive Culture
Numbers
25/33
Saudi Arabia* Saudi Arabia and UK **
Positive Culture 11/15 cases
Staphylococcus aureus 2
Pus Culture 63/86/136
Staphylococcus
aureus
Staphylococcus
aureus
15%
Staphylococcus
Coag. Negative
9%
Streptococcus 3
Enterococcus faecium 2
Escherichia coli 2
Bacteroides fragilis 1
Aspergillus 1
E. Coli 2nd MC
Bacterial liver abscess in children
J Singapore Paediatr Soc. 1989;31(1-
2):75-8
Tb 9%
Others 9%
Amoebic 30%
Parasitic 6%
Singapor
Most common
U.K.
*Liver Abscess in Children: A 10-year Single Centre Experience. Saudi J Gastroenterol. 2011 May-
Jun; 17(3): 199–202.
Liver Abscesses in Children: A Single Center Experience
in the Developed World. JPGN 42:201–206 February
Hepatic **abscesses Liver abscess presentation in childhood: and management retrospective in Saudi Arabia study and about the United 33 Kingdom. cases Ann observed Saudi
in
New-Caledonia Med. 2011 Sep-between Oct; 31(5): 528–1985 532.
and 2003. Arch Pediatr. 2004 Sep;11(9):1046-53

8. Organisms in PLA in India
A Srivastava et al.
Jan.2000-April 2008
SGPGI, Lucknow
Eur J Pediatr (2012)
171:33–41
Shamsul Bari et al
Jan. 1991 to Dec. 2000
Srinagar, Kashmir, India
Pediatr Surg Int (2007)
23:69–74
Staphylococcus – MC
Positive Pus Culture 15/39 39/70
S. aureus 8 30 (66%)
coagulase negative
Staphylococcus
f/b Gram negative bacteria
1
Acinetobacter
baumannii
anaerobes 2
( Bacteroides)
&
Enterococcus fecalis 1
Escherichia coli 2 7 (15%)
Pseudomonas 0 1 (4%)
Klebsiella 0 1 (4%)
Majority - poly-microbial

9. Which anti staphylococcus?
Chande CA et al. Prevalence of methicillin-resistant
Staphylococcus aureus nasopharyngeal carriage
in childrenfrom urban community at Nagpur.
– Indian J Public Health. 2009 Jul-Sep;53(3):196-8.
• Nasopharyngeal carriage of staphylococcus
aureus was detected in 7.38% children.
• Methicillin Resistant Staphylococci (MRSA)
constituted 4.16% of the Staphylococcus
aureus strains.
• Colonization rate of MRSA in the Paediatric
population in the community was detected to be 0.31%

10. Southern India

11. Revised treatment of PLA in
India
• An anti-staphylococcal
• Anti-anaerobic or
Anti-amoebic drug
• Third generation
cephalosporin (when colonic
source is suspected) or
aminoglycoside (when biliary
source is suspected)
Cloxacillin or
Vancomycin
Metronidazole or
Clindamycin
Cefotaxime or
Ceftriaxone
OR
Amikacin

12. Duration
• IV therapy x at least 2 weeks & then
• Followed by 4-6 weeks of oral treatment
After culture and sensitivity report, antibiotic
therapy directed at the specific organisms.

13. Resistance Pattern
• Not much data
• Only one study
• A combination of ampicillin plus aminoglycoside plus
metronidazole were used in patients with PLA for two
weeks intravenously and continued for four weeks orally
till about three years ago
• But because of growing antibiotic resistance, we now use
vancomycin plus imipenem, as empirical therapy, and then
change antibiotics according to the results of culture
• MC organism were Staph. Aureus 6 out of 8 positive cases
in 16 cases of PLA
– Liver Abscess in Children: A 10-year Single Centre
Experience between 1998 and 2008
• Saudi J Gastroenterol. 2011 May-Jun; 17(3): 199–202.

14. Antibiotics in Immunosuppressed
Conditions
• CGD patients
• Need to be put on prophylaxis
• DOC –
– Trimethoprim + Sulfamethaxozole
– Fluroquinolones
• Duration
– Months together
• Other drugs : IFN gamma once a week
• HSCT is curative

15. Choice of antibiotics in ALA
• Metronidazole x 7 – 10 days
• Alternative
– Tinidazole
– Chloroquine
• Followed by luminicidal x 10 days
– Idoquinole
– Diloxanide furoate
– Aminosidine

16. Other Treatment Modalities
• Single / Multiple Needle Aspirations
• Catheter Drainage
• Open Surgical Drainage

17. Other Modalities
• Shamsul Bari et al. Percutaneous aspiration versus open drainage of liver
abscess in children. Jan. 1991 to Dec. 2000.
• Srinagar, Kashmir, India.Pediatr Surg Int (2007) 23:69–74

18. Comparison
Parameter Pyogenic Liver Abscess
PLA
Amebic Liver Abscess
ALA
Number Often Multiple Usually single
Location Either lobe of liver Usually right hepatic
lobe, near the
diaphragm
Presentation Subacute Acute
Jaundice Mild Moderate
Diagnosis USG or CT ± Aspiration
Cluster sign on CT scan
USG/CT & amebic
serology (Titre ≥0.5)
Treatment Drainage + Antibiotics IV Metronidazole/
Tinidazole f/b Luminal
amebicidal

19. Summary
• Liver abscess is mostly pyogenic
• Staph. Aureus is MC organism
• Treatment modality is Drainage and IV antibiotics
• Choice of antibiotics is Cloxacillin
+
Cefotaxime
+
Metronidazole
• Duration at least 2 weeks of IV therapy
• F/b Oral treatment for 6 weeks
• Step down to specific antibiotics after culture & sensitivity
report
• Treatment of ALA is Metronidazole x 7 days f/b
oral Diloxanide furoate x 10 days

20. Thank you . . .