Pyogenic hepatic abscess: changing therapy?

Abstract

Objective: The authors document changes in the etiology, diagnosis, bacteriology, treatment, and outcome of patients with pyogenic hepatic abscesses over the past 4 decades. Summary Background Data: Pyogenic hepatic abscess is a highly lethal problem. Over the past 2 decades, new roentgenographic methods, such as ultrasound, computed tomographic scanning, direct cholangiography, guided aspiration, and percutaneous drainage, have altered both the diagnosis and treatment of these patients. A more aggressive approach to the management of hepatobiliary and pancreatic neoplasms also has resulted in an increased incidence of this problem. Methods: The records of 233 patients with pyogenic liver abscesses managed over a 42-year period were reviewed. Patients treated from 1952 to 1972 (n =80) were compared with those seen from 1973 to 1993 (n =153). Results: From 1973 to 1993, the incidence increased from 13 to 20 per 100,000 hospital admissions (p＜0.01). Patients managed from 1973 to 1993 were more likely (p＜0.01) to have an underlying malignancy (52% vs. 28%) with most of these (81%) being a hepatobiliary or pancreatic cancer. The 1973 to 1993 patients were more likely (p＜ .05) to be infected with streptococcal (53% vs. 30%) or Pseudomonas (30% vs. 9%) species or to have mixed bacterial and fungal (26% vs. 1%) infections. The recent patients also were more likely (p＜0.05) to be managed by percutaneous abscess drainage (45% vs. 0%). Despite having more underlying problems, overall mortality decreased significantly (p＜0.01) from 65% (in 1952 to 1972 period) to 31% (in 1973 to 1993 period). This reduction was greatest for patients with multiple abscesses (88% vs. 44%; p＜0.05) with either a malignant or a benign biliary etiology (90% vs. 38%; p＜0.05). Mortality was increased (p＜0.02) in patients with mixed bacterial and fungal abscesses (50%). From 1973 to 1993, mortality was lower (p=0.19) with open surgical as opposed to percutaneous abscess drainage (14% vs. 26%). Conclusions: Significant changes have occurred in the etiiology, diagnosis, bacteriology, treatment, and outcome of patients with pyogenic hepatic abscesses over the past 4 decades. However, mortality remains high, and proper management continues to be a challenge. Appropriate systemic antibiotics and fungal agents as well as adequate surgical, percutaneous, or biliary drainage are required for the best results.