Microbiology of liver abscesses and the predictive value of abscess gram stain and associated blood cultures

doi:10.1016/S0732-8893(03)00088-9

Diagnostic Microbiology and Infectious Disease

Volume 46, Issue 4, August 2003, Pages 245-248

Presented in part as a poster at the 101^st General Meeting of the American Society for Microbiology, Orlando, Florida, 2001.

https://doi.org/10.1016/S0732-8893(03)00088-9 Get rights and content

Abstract

Although rare, pyogenic liver abscesses are potentially fatal. We evaluated the predictive value of Gram stain of liver abscess aspirates and temporally associated blood cultures. Gram stains detected bacteria in 79% of the liver abscesses tested. The sensitivity and specificity of Gram stain of the liver abscesses were 90% and 100% for Gram-positive cocci (GPC) and 52% and 94% for Gram-negative bacilli (GNB). The sensitivities of the blood cultures for any GPC and GNB present in the liver abscess were 30% and 39%, respectively. Although, Gram stains and blood cultures offer incomplete detection of the microbial contents of pyogenic liver abscesses, both tests should always accompany liver abscess cultures.

Introduction

Although rare, pyogenic liver abscesses are potentially fatal if surgical drainage and appropriate antimicrobial therapy are not instituted early in the course of the disease Bertel et al 1986, Huang et al 1996, Seeto and Rockey 1996. Because early diagnosis and treatment are essential for patient survival, we evaluated the predictive value, sensitivity, and specificity of Gram stain of liver abscess aspirates, and of temporally associated blood cultures. Our goal was to ascertain the usefulness of these microbiologic tests in establishing the causative organism(s) of a liver abscess, which has therapeutic implications.

Section snippets

Patient selection

Thirty-eight patients with 40 episodes of liver abscess identified at our institution from October 1995 to November 2000 were selected from the computerized microbiology database. Patients included in the study met all of the following criteria: 1) they had a clinical diagnosis of liver abscess, 2) a diagnostic radiologic study was available, and 3) a bacterial culture from the liver abscess was positive. We reviewed demographics, associated diseases, Gram stain results from the liver

Results

The mean age of the 38 patients with liver abscess was 56 years [range: 15-82], and 23 (61%) were male. Of these 38 patients, 18 (47%) had had recent abdominal surgery (including liver transplantation, Whipple’s procedure, cholecystectomy, Billroth II, and small bowel resection), 18 (47%) had biliary tract and/or liver disease, 12 (32%) had an intra-abdominal neoplasm (including cholangiocarcinoma, pancreatic cancer, colon and gastric adenocarcinoma, and intraabdominal desmoid tumor), and 2

Discussion

Almost half of the patients in this review had had recent abdominal surgery and had biliary tract and/or liver disease before developing a liver abscess. Only 2 of the 38 patients had no predisposing factors contributing to liver abscesses (i.e., cryptogenic abscesses). Oschner et al., in their classic paper from 1938, noted that liver abscesses mainly affected young male patients with intra-abdominal infections, usually pylephlebitis secondary to acute appendicitis (Oschner et al., 1938).

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In patients with sepsis, physicians must obtain a blood culture to identify the causative bacteria and start antibiotic treatment as soon as possible to decrease mortality [5–8]. In patients with liver abscesses, the proportion of positive blood cultures is relatively low (up to 50%) [9,10]. Therefore, some physicians may delay antibiotic treatment to avoid lowering the culture yield for abscess specimens when the patients are relatively stable.
The optimal timing of antibiotic administration in patients with a liver abscess undergoing liver aspiration or drainage is unknown.
This was a retrospective cohort study using the Diagnosis Procedure Combination database, a national inpatient database in Japan.
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Liver abscess is an uncommon entity that over the past 100 years has seen changes in demographics, etiology, diagnosis, and treatment. Traditionally it has been useful to think of hepatic abscesses in two broad categories: those of bacterial origin, otherwise known as pyogenic liver abscess (PLA), and those of parasitic origin primarily caused by Entamoeba histolytica leading to amebic liver abscess (ALA). The principles of treatment of PLA are to drain the abscess cavity, identify the pathogen, initiate appropriate antibiotic therapy, and treat any underlying disease process associated with the abscess, while standard treatment for ALA includes amebicidal drugs. Improvements in mortality and morbidity appear to be associated with early diagnosis, refinements in diagnostic imaging in the form of ultrasound and CT scan, as well as the evolution of minimally invasive percutaneous aspiration and drainage techniques. Improvements in antibiotic usage and the development of critical care medicine have likely also contributed to further reductions in mortality from these diseases.
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A total of 528 patients were treated as CNPLA or KPPLA over the study period. CNPLA presented more commonly with abdominal pain (P=0.024). KPPLA was more common in older age (P=0.029) and was associated with thrombocytopenia (P=0.001), elevated creatinine (P=0.002), bilirubin (P=0.001), alanine aminotransferase (P=0.006) and C-reactive protein level (P=0.036). CNPLA patients tend to have anemia (P=0.015) and smaller abscess (P=0.008). There was no difference in hospital stay (15.7 vs 16.8 days) or mortality (14.0% vs 11.0%). No patients required surgical drainage after initiation of medical therapy.
Despite demographic and clinical differences between CNPLA and KPPLA, overall outcomes are not different.
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Diagnostic Microbiology and Infectious Disease

Abstract

Introduction

Section snippets

Patient selection

Results

Discussion

References (15)

Pyogenic liver abscesses

Infect Dis Clin North Am

Is the stat Gram stain helpful during percutaneous image-guided fluid drainage?

Acad Radiol

Pyogenic abscess of the liver. II. An analysis of forty-seven cases with review of the literature

Am J Surg

The role of intraoperative Gram stain in the diagnosis of infection during revision total hip arthroplasty

J Arthroplasty

Treatment of pyogenic liver abscesses. Surgical vs percutaneous drainage

Arch Surg

The diagnostic value of Gram stain for initial identification of the etiologic agent of peritonitis in CAPD patients

Perit Dial Int

Hepatic abscess

Changes in etiology, diagnosis and management. Ann Surg

Cited by (52)

Outcomes after early versus delayed antibiotic treatment of liver abscess in Japan: A nationwide retrospective cohort study

Liver Abscess

Liver abscess

Patients with culture negative pyogenic liver abscess have the same outcomes compared to those with Klebsiella pneumoniae pyogenic liver abscess

Clinical ultrasound in the emergency room on a septic patient

Gallbladder Disease and Hepatic Infections

BacteriologyMicrobiology of liver abscesses and the predictive value of abscess gram stain and associated blood cultures

Abstract

Introduction

Section snippets

Patient selection

Results

Discussion

Infect Dis Clin North Am

Acad Radiol

Am J Surg

J Arthroplasty

Treatment of pyogenic liver abscesses. Surgical vs percutaneous drainage

Arch Surg

The diagnostic value of Gram stain for initial identification of the etiologic agent of peritonitis in CAPD patients

Perit Dial Int

Hepatic abscess

Changes in etiology, diagnosis and management. Ann Surg

Bacteriology
Microbiology of liver abscesses and the predictive value of abscess gram stain and associated blood cultures