INTERNATIONAL JOURNAL OF MEDICAL AND APPLIED SCIENCES

ISSN:2320‐3137

Research Article

PYOGENIC LIVER ABSCESS: FRESH LOOK AT ITS

CONTINUING CHANGING PATTERNS
Anjana Gopi1*, Rashmi M2, Shaik Mohammed Usman3, Rashmi KS4, Divya
H5, Neetha SM5, Hitha TK5, Misbah-ul-khair S5
1*
Associate Professor, Department of Clinical Microbiology, Kempegowda Institute of medical
sciences and research centre, Bangalore, India.
2
Senior registrar- Clinical Microbiology and Infection control, Sagar Hospitals-DSI,
Bangalore, India
3
Assistant Professor, Department of Clinical Microbiology and Infection control, Kannur
Medical college & super speciality hospital, Kannur, India.
4
Assistant Professor, Department of Clinical Microbiology, Kempegowda Institute of medical
sciences and research centre, Bangalore, India.
5
Tutor, Department of Clinical Microbiology, Kempegowda Institute of medical sciences and
research centre, Bangalore, India.

ABSTRACT

Pyogenic liver abscess (PLA), a dominant hepatobiliary life-threatening infection has undergone significant
alterations in its epidemiology, causative agents and mortality over time. The incidence is likely to increase because
of ageing population, increasing immunocompromised patients, raising transplantation rates and improved detection
due to advances in imaging. Because of its sparse documentation, we reviewed the cases of PLA to put forth our
experience of clinical silhouette and causative organisms. This prospective clinico-microbiological review,
undertaken between January 2011 and December 2012, studied pus sample of liver abscess cases diagnosed
clinically and radiologically with abscess volume of >200cc or size of >5cms (obtained by different surgical means)
by standard microbiological techniques. 84 cases were subjected to diagnostic and therapeutic removal of pus by
various means. There were 45 positive cultures with a preponderant Enterococcus spp. (44.44%), followed by
Klebsiella pneumoniae, Escherichia coli (24.44% each) and Staphylococcus aureus (6.67%). Polymicrobial infection
was seen in four cases. High susceptibility was exhibited against most of the drugs. Association with diabetes was
considerable (29.46%). Only 3 cases exhibited positive HIV serology. No mortality was observed. In consideration
of the scant observations made in India of this condition and due to the significant alterations, this condition has
withstood over a period of time; it is imperative to make a surveillance record for formulation of better management
approaches. Though not frequently seen, this potentially troublesome condition once contemplated to be lethal has
lately been shown to have a substantially decreased mortality.
Key words: Liver abscess, Enterococcus, Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus.

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INTRODUCTION condition. This incited us to take up this

Pyogenic liver abscess (PLA) was recorded task, aiming to delineate microbiological
in the writings of Hippocrates, who profile and clinical peculiarities of this
estimated prognosis on the type of fluid condition at a tertiary care centre, with a
recovered from the abscess.[1] perspective of patterning the antimicrobial
Liver abscess may be solitary or multiple; susceptibility of etiological agents.
may arise from hematogenous spread of MATERIALS AND METHODS
bacteria or from local spread from
contiguous sites of infection within the In this prospective study, 112 patients
peritoneal cavity. The etiology and diagnosed clinically and/or
management of PLA has changed ultrasonographically(USG) [Figure-1] to
substantially in the past few decades. In the have Liver Abscess attending General
first half of last century and prior to the Surgery-OPD, Casualty and Inpatient
introduction of antibiotics, suppurative department, Kempegowda Institute of
appendicitis with portal phlebitis was the Medical Sciences and Research Centre-
most common etiology of this condition.[2] Bangalore, between January 2011 and
Recently, hepatobiliary causes have replaced December 2012 were studied. Demographic
portal phlebitis and hematogenous spread as factors such as age, gender; underlying
the most common identifiable source of conditions (such as DM, HIV infection,
PLA. Ascending infection via the biliary Biliary tract diseases); clinical features and
system is now the single largest identified radiological profile were noted. USG guided
cause of pyogenic liver abscess, accounting aseptic percutaneous aspiration [Figure-3] /
for approximately one-half of all cases.[3] Pig tail catheter drainage / Laporotomy /
Laporoscopy was done for 84 cases with
Most causative organisms are of bowel abscess volume of >200cc or size of >5cms.
origin, with Escherichia coli, Klebsiella The aspirate was immediately subjected to
pneumoniae, Bacteroides, Enterococci, Microscopic examination- Wet mount to
anaerobic Streptococci, and microaerophilic detect the presence of Amebic trophozoites,
Streptococci- being the most regular. Gram staining to demonstrate bacteria and
Hepatic abscess may be caused by Zeihl-Neelsen staining to rule out
Mycobacteria, though this is extremely rare. Mycobacterial infection. The sample was
However, of the few patients with acquired also used for culture and further incubated
immunodeficiency syndrome presenting on MacConkey's agar, Blood agar (in a CO2
with hepatic abscess, Mycobacterium incubator) for upto 72 hrs and in
tuberculosis is a common infecting Thioglycollate broth for upto 7 days. The
organism.[4] grown organism was identified by colony
morphology, Gram staining, appropriate
The incidence is likely to increase. biochemical tests.[5] Antimicrobial
Documentation of the encounters is essential suceptibility of the obtained isolate was
in order to better understand and tackle this done by Kirby-Bauer's disc diffusion

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method using Commercially available disks Standards Institute (CLSI)[6] guidelines.

(Himedia Laboratories, Mumbai) and Mean antibiogram was calculated. Patients
interpreted as per Clinical laboratory were followed up to spot the recurrence.

Fig. 1: USG picture showing abscess cavity in right lobe of liver – evolving abscess (7.5 x
4.5 cms)

Fig. 2: Elevated Right lobe of diaphragm due to a liver abscess in a X‐ray.

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Fig. 3: Percutaneous aspiration (creamy white pus)-USG guided

RESULTS staining correlated well with the subsequent

The cases diagnosed to have Liver Abscess culture results. Culture yielded positive
in this prospective study, ranged in age from results in 45/84 (53.57%) of these cases.
19-75 years with mean being 47 years. The Predominant organism obtained was
peak incidence occurred in fourth and sixth Enterococcus spp. (44.44%). Klebsiella
decades. Male to female ratio was pneumoniae and Escherichia coli were the
7:1.[Table-1] other organisms cultured (24.44% each).
Around 85% of the patients were Alcoholic. Staphylococcus aureus on culture was
Positive HIV serology was found in only 3 obtained from three samples (6.67%).
cases. Association of Diabetes in our series Polymicrobial infection was seen in four
was 29.46%.[Table-2] cases (4/112). [Table-3]
The most common features at presentation Antibiogram revealed favourable reports.
were pain abdomen (100%), abdominal There was resistance to three or more
tenderness (100%) and fever (90.18%). classes of drugs in 8.89%(4/45) of isolates.
Cough, jaundice and diarrhea were found There was no Methicillin resistance in
inconsistently. Acute onset of symptoms (<7 Staphylococcus aureus (When tested using
days) was the commonest mode of cefoxitin discs in disc diffusion)[6]. Only
presentation (59.82%). Majority were one Klebsiella pneumoniae was found to be
cryptogenic (101/112), but Alcoholism an ESBL producer (detected using
(95/112) & Diabetes mellitus (33/112) were phenotypic confirmatory test)[6]. High
found as the major risk factors. susceptibility was noticed against all the
Leukocytosis could be demonstrated in drugs except Ciprofloxacin (60.87%) and
72.32% of cases. All patients had more than Cotrimoxazole (43.48%) in Gram positive
one abnormality in the panel of liver bacteria, while in Gram-negative bacteria
function tests. USG abdomen done in all least susceptibility was witnessed against
cases displayed multiple abscesses in Ampicillin (0%) and Amoxycillin-clavulanic
22.32%. Isolated right lobe abscesses were acid (0%). [Table-4]
seen in 94.64% cases of solitary abscesses. Mean Duration of Follow-up in our study
was around 8.63 months. Fortunately there
No amoebic trophozoites were detected on was no mortality rate. There was recurrence
Wet Mount examination. Zeihl-Neelsen in 4 cases which were prior infected with
staining was negative for all samples. Gram Klebsiella pneumoniae.

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Table-1: Age and gender profile of the patients:

Number of patients
Age in years Male Female
(%)
11-20 5 4 9(8.03%)

21-30 13 2 15(13.39%)

31-40 23 3 26 (23.21%)

41-50 22 1 23(20.53%)

51-60 27 2 29(24.11%)

>60 8 2 10 (8.93%)

Table-2:Underlying conditions:

Number of
Underlying conditions
diagnosed cases =112
Cryptogenic 101

Biliary 08

HIV 03

TB 00

Table-3:Microbiology of pyogenic abscesses:

Number
of Solitary Multiple
PUS culture
patients Abscess Abscess
(n=84)
Enterococcus spp. 20 13 7

Klebsiella pneumoniae 11 9 0

Escherichia coli 11 7 4

Staphylococcus aureus 3 2 1

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Table-4: Mean Antibiogram

Mean Antibiotic susceptibility of the isolates - %

Antimicrobial agent Gram-positive Antimicrobial agent Gram-negative

bacteria tested bacteria tested

Amoxycillin/Clavulanic 78.26 Amoxycillin/Clavulanic 0

acid acid

Cloxacillin 73.91 Ampicillin 0

Linezolid 100 Piperacillin-Tazobactam 100

Vancomycin 100 Cefepime 72.73

Cefepime 82.61 Cefoperazone 90.91

Cefoperazone 78.26 Cefuroxime 81.82

Gentamicin 86.96 Imipenem 100

Erythromycin 78.26 Amikacin 100

Clindamycin 82.61 Gentamicin 100

Tetracycline 86.96 Ciprofloxacin 72.73

Ciprofloxacin 60.87 Levofloxacin 100

Cotrimoxazole 43.48 Cotrimoxazole 63.64

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DISCUSSION
Only 1 patient was found to be infected with
Pyogenic hepatic abscess is a bothersome ESBL-producing Klebsiella pneumoniae.
condition. Although relatively uncommon, This is consistent with reports from Taiwan,
its incidence is not decreasing and should be where isolates of Klebsiella pneumoniae
expected to increase. The epidemiology, causing PLA have all been highly
causative agents, and mortality rate for cases susceptible[19]. The cases from Taiwan
of PLA have changed remarkably from the involving Klebsiella species were also
initial case descriptions. In our study, mostly monomicrobial, which agrees with
highest incidence was found of patients in the findings of our report.
fourth and sixth decades (mean age-47
years), which is comparable to other Our study has one of the lowest reported
studies[7,8]. Our observations of large mortality rates for PLA. Other studies have
preponderance of male patients was also also demonstrated a progressive decrease in
consistent with some prior reports.[9,10] mortality rates.[13,14,20] This may be due
These changes are likely to be caused by in part to improved imaging and diagnostic
changes in the prevailing causes of PLA. techniques, as well as to increased use of
percutaneous drainage and due to the high
Most of the patients present in this series degree of antimicrobial susceptibility of
presented with right upper quadrant pain, causative organisms.
fever which were also the major features
observed in other series.[7,9] Our finding of The results represent the experience from a
a predominance of right-side abscesses was single centre, and may not be generalizable
in accordance with other to other areas with different epidemiologic
studies.[11,12,13,14]. or clinical settings.

Most of our cases were considered CONCLUSION

cryptogenic. Alcoholism, a major risk factor
associated here, was also a dominant PLA, though less frequently seen is a
association in another study [9]. The common condition in India, but the
noticeable association of Diabetes mellitus observations have not been put forth widely.
as seen in our study is also depicted in some PLA was once considered to be a highly
other studies.[13,14] Our study showed fatal disease but has recently been associated
Enterococcus as the predominant agent. This with low mortality. With a keen focus on its
was in contrast to many other studies. In microbiology, this study highlights the trend
reports from the United States, the most of this clinical condition. Regular
frequent organism recovered from patients surveillance is indispensable to define
has been Escherichia coli.[12,13,15] Recent appropriate management strategies. This
reports have described an increase in the work re-emphasizes that timely diagnosis
rate of PLA due to Klebsiella and prompt institution of treatment
pneumoniae.[16,17] Recently PLA individualized to the patient remains the
secondary to Klebsiella pneumoniae has standard of care to scale down the mortality
emerged as a distinct clinical entity in rates.
diabetic patients in a study.[18] Infection
with Klebsiella pneumoniae showed a
tendency to recur.

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