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Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, Todi SK, Mohan A, Hegde A, Jagiasi BG, Krishna B, Rodrigues C, Govil D, Pal D, Divatia JV, Sengar M, Gupta M, Desai M, Rungta N, Prayag PS, Bhattacharya PK, Samavedam S, Dixit SB, Sharma S, Bandopadhyay S, Kola VR, Deswal V, Mehta Y, Singh YP, Myatra SN. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024; 28:S104-S216. [PMID: 39234229 PMCID: PMC11369928 DOI: 10.5005/jp-journals-10071-24677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 09/06/2024] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Subhash K Todi
- Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Ashit Hegde
- Department of Medicine & Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, India
| | - Camila Rodrigues
- Department of Microbiology, P D Hinduja National Hospital, Mumbai, India
| | - Deepak Govil
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Divya Pal
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mukesh Desai
- Department of Immunology, Pediatric Hematology and Oncology Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Narendra Rungta
- Department of Critical Care & Anaesthesiology, Rajasthan Hospital, Jaipur, India
| | - Parikshit S Prayag
- Department of Transplant Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Susruta Bandopadhyay
- Department of Critical Care, AMRI Hospitals Salt Lake, Kolkata, West Bengal, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vikas Deswal
- Consultant, Infectious Diseases, Medanta - The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Yogendra P Singh
- Department of Critical Care, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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AYONGA NDEBA P, AKONKWA Y, WONE F, GOURARI S. [Pyogenic hepatic abscess secondary to gastric perforation by a foreign body complicated by acute peritonitis: about a case at the Hôpital Principal de Dakar, Senegal]. MEDECINE TROPICALE ET SANTE INTERNATIONALE 2024; 4:mtsi.v4i1.2024.390. [PMID: 38846121 PMCID: PMC11151909 DOI: 10.48327/mtsi.v4i1.2024.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 01/29/2024] [Indexed: 06/09/2024]
Abstract
Accidental ingestion of a foreign body into the gastrointestinal tract is not uncommon, however the development of hepatic abscesses secondary to digestive perforation by a foreign body is rare. We report the case of pyogenic hepatic abscesses secondary to gastric perforation by a fishbone complicated by acute peritonitis. A 53-year-old patient was admitted to our hospital with the main complaints: diffuse abdominal pain with vomiting in a context of fever and physical asthenia. A painful febrile hepatomegaly with jaundice was objectified, as well as a non-specific biological inflammatory syndrome. An initial abdominopelvic CT scan revealed multifocal liver abscesses. Faced with the initial therapeutic failure associating parenteral antibiotic therapy and abscess drainage, a second abdominal CT scan identified a foreign body straddling the antropyloric wall and segment I of the liver.A xypho-pelvic midline laparotomy was performed with nearly 200 cc of peritoneal fluid coming out. A fishbone approximately 5 cm long was extracted by laparotomy, followed by gastric closure with omentum, peritoneal cleansing and drainage. Symptomatic adjuvant treatment was initiated, including a proton pump inhibitor (Pantoprazole). He also benefited from transfusion support in the face of anemia. Antibiotic therapy was continued for a total of 2 weeks after surgery. The evolution was favorable with follow-up imaging at 3 months, showing complete resorption of the hepatic abscesses.
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Affiliation(s)
- Patrick AYONGA NDEBA
- Université Cheikh Anta Diop (UCAD), Faculté de médecine, pharmacie et odontologie, Dakar, Sénégal
- Service des maladies infectieuses et tropicales, Centre hospitalier universitaire national Fann (CHUNF), Dakar, Sénégal
| | - Yvette AKONKWA
- Université Cheikh Anta Diop (UCAD), Faculté de médecine, pharmacie et odontologie, Dakar, Sénégal
- Service d'hépato-gastro-entérologie et chirurgie digestive, Hôpital Principal de Dakar (HPD), Dakar, Sénégal
| | - Fatimata WONE
- Université Cheikh Anta Diop (UCAD), Faculté de médecine, pharmacie et odontologie, Dakar, Sénégal
- Département de médecine interne et maladies infectieuses, Pavillon Boufflers, Hôpital Principal de Dakar (HPD), Dakar, Sénégal
| | - Sihem GOURARI
- Service de médecine interne et maladies infectieuses, Centre hospitalier de Périgueux, Périgueux, France
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Fansiwala K, Rusher A, Shore B, Herfarth HH, Barnes E, Kochar B, Chang S. Oral vs Intravenous Discharge Antibiotic Regimens in the Management of Intra-abdominal Abscesses in Penetrating Crohn's Disease. Inflamm Bowel Dis 2023:izad299. [PMID: 38150318 DOI: 10.1093/ibd/izad299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Antibiotics are a cornerstone in management of intra-abdominal abscesses in Crohn's disease (CD). Yet, the optimal route of antibiotic administration is poorly studied. We aimed to compare surgical and nonsurgical readmission outcomes for patients hospitalized for intra-abdominal abscesses from CD discharged on oral (PO) or intravenous (IV) antibiotics. METHODS Data for patients with CD hospitalized for an intra-abdominal abscess were obtained from 3 institutions from January 2010 to December 2020. Baseline patient characteristics were obtained. Primary outcomes of interest included need for surgery and hospital readmission within 1 year from hospital discharge. We used multivariable logistic regression models and Cox regression analysis to adjust for abscess size, history of prior surgery, history of penetrating disease, and age. RESULTS We identified 99 patients discharged on antibiotics (PO = 74, IV = 25). Readmissions related to CD at 12 months were less likely in the IV group (40% vs 77% PO, P = .01), with the IV group demonstrating a decreased risk for nonsurgical readmissions over time (hazard ratio, 0.376; 95% confidence interval, 0.176-0.802). Requirement for surgery was similar between the groups. There were no differences in time to surgery between groups. CONCLUSIONS In this retrospective, multicenter cohort of CD patients with intra-abdominal abscess, surgical outcomes were similar between patients receiving PO vs IV antibiotics at discharge. Patients treated with IV antibiotics demonstrated a decreased risk for nonsurgical readmission. Further prospective trials are needed to better delineate optimal route of antibiotic administration in patients with penetrating CD.
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Affiliation(s)
- Kush Fansiwala
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Alison Rusher
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Shore
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Shannon Chang
- Inflammatory Bowel Disease Center, Division of Gastroenterology, NYU Grossman School of Medicine, New York, NY, USA
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Patel S, Southall C, Varghese R. Multifocal hepatic abscess post-ERCP. BMJ Case Rep 2023; 16:e256578. [PMID: 38114294 DOI: 10.1136/bcr-2023-256578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
A woman in her 40s presented to hospital with cholangitis. A magnetic resonance cholangiopancreatography showed a moderately dilated common bile duct and mild intrahepatic duct dilatation with sludge. She underwent a successful endoscopic retrograde cholangiopancreatography (ERCP) and sphincteroplasty. She subsequently developed recurrence of fevers and abdominal pain with rising inflammatory markers. Initial investigations and imaging were unremarkable. A positron emission tomography scan demonstrated multiple fluorodeoxyglucose (FDG)-avid hepatic lesions, and subsequent imaging confirmed multifocal liver abscesses without a drainable collection. The patient was managed with intravenous co-amoxiclav initially before switching to oral antibiotics, however, represented 1 week later with similar symptoms. Her antibiotic coverage was broadened to intravenous pipercillin-tazobactam, and she was discharged on this with follow-up in clinic. This case report highlights the rare complication of hepatic abscesses following ERCP and the importance of considering this as a differential in patients who present with sepsis following the procedure.
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Affiliation(s)
- Samit Patel
- General Medicine, Armadale Health Service, Armadale, Western Australia, Australia
| | - Clea Southall
- General Medicine, Armadale Health Service, Armadale, Western Australia, Australia
| | - Roy Varghese
- General Medicine, Armadale Health Service, Armadale, Western Australia, Australia
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Curran J, Mulhall C, Pinto R, Bucheeri M, Daneman N. Antibiotic treatment durations for pyogenic liver abscesses: A systematic review. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2023; 8:224-235. [PMID: 38058494 PMCID: PMC10697100 DOI: 10.3138/jammi-2023-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/03/2023] [Indexed: 12/08/2023]
Abstract
Background We sought to systematically review the existing research on pyogenic liver abscesses to determine what data exist on antibiotic treatment durations. Methods We conducted a systematic review and meta-analysis of contemporary medical literature from 2000 to 2020, searching for studies of pyogenic liver abscesses. The primary outcome of interest was mean antibiotic treatment duration, which we pooled by random-effects meta-analysis. Meta-regression was performed to examine characteristics influencing antibiotic durations. Results Sixteen studies (of 3,933 patients) provided sufficient data on antibiotic durations for pooling in meta-analysis. Mean antibiotic durations were highly variable across studies, from 8.4 (SD 5.3) to 68.9 (SD 30.3) days. The pooled mean treatment duration was 32.7 days (95% CI 24.9 to 40.6), but heterogeneity was very high (I2 = 100%). In meta-regression, there was a non-significant trend towards decreased mean antibiotic treatment durations over later study years (-1.14 days/study year [95% CI -2.74 to 0.45], p = 0.16). Mean treatment duration was not associated with mean age of participants, percentage of infections caused by Klebsiella spp, percentage of patients with abscesses over 5 cm in diameter, percentage of patients with multiple abscesses, and percentage of patients receiving medical management. No randomized trials have compared treatment durations for pyogenic liver abscess, and no observational studies have reported outcomes according to treatment duration. Conclusions Among studies reporting on antibiotic durations for pyogenic liver abscess, treatment practices are highly variable. This variability does not seem to be explained by differences in patient, pathogen, abscess, or management characteristics. Future RCTs are needed to guide optimal treatment duration for patients with this complex infection.
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Affiliation(s)
- Jennifer Curran
- Antimicrobial Stewardship Program, Sinai Health/University Health Network, Toronto, Ontario, Canada
| | | | | | - Mohamed Bucheeri
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Abstract
Pyogenic liver abscesses (PLAs) are a suppurative infection of the hepatic parenchyma responsible for significant morbidity and mortality. PLAs are categorized into a variety of mechanisms: (1) via the portal vein, (2) through the biliary tract, (3) via the hepatic artery, (4) from trauma, (5) contiguously via direct extension, and (6) cryptogenically. The pathogenesis of PLA, which informs treatment, can often be discerned based on host factors, clinical presentation, and causative microorganisms. The Streptococcus anginosus group, hypervirulent Klebsiella pneumoniae , and multidrug-resistant gram-negative pathogens have emerged as microbiologically challenging organisms to treat. The identification of hypervirulent K. pneumoniae should prompt for assessment for metastatic spread and consideration of prolonged antimicrobial treatment. Abdominal imaging is indispensable in characterizing PLAs and facilitating source control interventions. Source control remains the most critical aspect of PLA management, followed by antimicrobial therapy. Empiric antibiotics for PLAs are informed by the suspected etiology of PLA formation. Duration of antimicrobial therapy is individualized and dependent on multiple components, including the success of achieving source control, host factors, mechanism of PLA development, and the illness course of the individual-factoring in clinical, biochemical, and radiographic parameters.
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Affiliation(s)
- John C Lam
- Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, CA
| | - William Stokes
- Provincial Laboratory for Public Health, Alberta Precision Laboratories, Calgary
- Department of Pathology and Laboratory Medicine, University of Alberta
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Wang JH, Gao ZH, Qian HL, Li JS, Ji HM, Da MX. Treatment of pyogenic liver abscess by surgical incision and drainage combined with platelet-rich plasma: A case report. World J Clin Cases 2022; 10:7082-7089. [PMID: 36051112 PMCID: PMC9297389 DOI: 10.12998/wjcc.v10.i20.7082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/10/2022] [Accepted: 05/28/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pyogenic liver abscesses are insidious in the early stage. Some cases progress rapidly, and the patient’s condition can worsen and even become life-threatening if timely treatment is not provided. Surgery and prolonged antibiotic treatment are often required if the abscess is large and liquefied and becomes separated within the lumen.
CASE SUMMARY We report a case of bacterial liver abscess with a poor outcome following pharmacological treatment, review the literature related to the use of platelet-rich plasma (PRP) in the treatment of hepatic impairment and partial hepatectomy in animals, and discuss the prognostic features of surgical incision and drainage combined with PRP in the treatment of bacterial liver abscesses. This is the first case describing the use of PRP in the treatment of a bacterial liver abscess in humans, providing new ideas for the treatment of this condition.
CONCLUSION This case highlights the importance of surgical treatment for bacterial liver abscesses that are well liquefied and poorly managed medically. PRP may produce antimicrobial effects and promote the regeneration and repair of liver tissue.
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Affiliation(s)
- Jun-Hong Wang
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
- Department of Hepatobiliary Surgery, The First People’s Hospital of Baiyin, Baiyin 730900, Gansu Province, China
| | - Zhen-Hua Gao
- Department of Hepatobiliary Surgery, The First People’s Hospital of Baiyin, Baiyin 730900, Gansu Province, China
| | - Hong-Liang Qian
- Department of Hepatobiliary Surgery, The First People’s Hospital of Baiyin, Baiyin 730900, Gansu Province, China
| | - Jin-Shun Li
- Department of Hepatobiliary Surgery, The First People’s Hospital of Baiyin, Baiyin 730900, Gansu Province, China
| | - Hao-Min Ji
- Department of Hepatobiliary Surgery, The First People’s Hospital of Baiyin, Baiyin 730900, Gansu Province, China
| | - Ming-Xu Da
- The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
- Department of General Surgery, People’s Hospital of Gansu Province, Lanzhou 730000, Gansu Province, China
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Giangiuli SE, Mueller SW, Jeffres MN. Transition to Oral versus Continued Intravenous Antibiotics for Patients with Pyogenic Liver Abscesses: A Retrospective Analysis. Pharmacotherapy 2019; 39:734-740. [PMID: 31148192 DOI: 10.1002/phar.2296] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The management of pyogenic liver abscesses usually requires 4 weeks of antibiotic therapy. It is unknown if oral (PO) antibiotics are as effective as intravenous (IV) antibiotics for this indication. OBJECTIVES To compare 30-, 60-, and 90-day readmission rates between patients with pyogenic liver abscesses receiving IV antibiotics for the duration of therapy and those who were transitioned to PO antibiotics after discharge from the hospital. METHODS This retrospective study included patients with pyogenic liver abscesses who had undergone percutaneous drainage and received IV antibiotics while in the hospital. Patients were grouped based on receipt of either PO or IV antibiotics at discharge. RESULTS The final cohort resulted in 99 patients, 48 in the PO group and 51 in the IV group. The most common organisms identified were Klebsiella sp, Escherichia coli, and Streptococcus sp. The most common antibiotic received at discharge in the IV group was ertapenem or ceftriaxone plus metronidazole. Patients in the PO group most commonly received levofloxacin plus metronidazole at discharge. Thirty-day readmission occurred more frequently in the PO group (PO 39.6% vs IV 17.6%, p=0.03). The most common reasons for readmission were complications related to abscess or antibiotic. Univariate logistic regression for readmission identified PO antibiotics at discharge as an independent predictor of readmission at 30 days (odds ratio [OR] 3.1), 60 days (OR 3.9), and 90 days (OR 3.1). CONCLUSION Transition to PO antibiotics that consisted mostly of fluoroquinolones for patients with pyogenic liver abscesses was associated with a higher rate of 30-day readmission compared with patients treated with IV antibiotics that consisted mostly of β-lactams.
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Affiliation(s)
- Stephanie E Giangiuli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Scott W Mueller
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
| | - Meghan N Jeffres
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colorado
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Molton J, Phillips R, Gandhi M, Yoong J, Lye D, Tan TT, Fisher D, Archuleta S. Oral versus intravenous antibiotics for patients with Klebsiella pneumoniae liver abscess: study protocol for a randomized controlled trial. Trials 2013; 14:364. [PMID: 24176222 PMCID: PMC4228424 DOI: 10.1186/1745-6215-14-364] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 10/04/2013] [Indexed: 11/29/2022] Open
Abstract
Background Klebsiella pneumoniae liver abscess is the most common etiology of liver abscess in Singapore and much of Asia, and its incidence is increasing. Current management includes prolonged intravenous antibiotic therapy, but there is limited evidence to guide oral conversion. The implicated K1/K2 capsule strain of Klebsiella pneumoniae is almost universally susceptible to ciprofloxacin, an antibiotic with high oral bioavailability. Our primary aim is to compare the efficacy of early (< one week) step-down to oral antibiotics, to continuing four weeks of intravenous antibiotics, in patients with Klebsiella liver abscess. Methods/design The study is designed as a multi-center randomized open-label active comparator-controlled non-inferiority trial, with a non-inferiority margin of 12%. Eligible participants will be inpatients over the age of 21 with a CT or ultrasound scan suggestive of a liver abscess, and Klebsiella pneumoniae isolated from abscess fluid or blood. Randomization into intervention or active control arms will be performed with a 1:1 allocation ratio. Participants randomized to active control will receive IV ceftriaxone 2 grams daily to complete a total of four weeks of IV antibiotics. Participants randomized to intervention will be immediately converted to oral ciprofloxacin 750 mg twice daily. At Week four, all participants will undergo abdominal imaging and be assessed for clinical response (CRP < 20 mg/l, absence of fever, plus scan showing that the maximal diameter of the abscess has reduced). If criteria are met, antibiotics are stopped; if not, oral antibiotics are continued, with reassessment for clinical response fortnightly. If criteria for clinical response are met by Week 12, the primary endpoint of clinical cure is met. A cost analysis will be performed to assess the cost saving of early conversion to oral antibiotics, and a quality of life analysis will be performed to assess whether treatment with oral antibiotics is less burdensome than prolonged IV antibiotics. Discussion Our results would help inform local and international practice guidelines regarding the optimal antibiotic management of Klebsiella liver abscess. A finding of non-inferiority may translate to the wider adoption of a more cost-effective strategy that reduces hospital length of stay and improves patient-centered outcomes and satisfaction. Trial registration Clinical trials gov NCT01723150
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Affiliation(s)
| | | | | | | | | | | | | | - Sophia Archuleta
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore, Singapore.
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MacFadden DR, Penner TP, Gold WL. Persistent epigastric pain in an 80-year-old man. CMAJ 2011; 183:925-8. [PMID: 21398231 DOI: 10.1503/cmaj.101510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Malik I, Ghosh S, Nutt C, Macdonald A, Bal AM, Collier A. Gemella haemolysans Bacteraemia in a Patient with Solitary Liver Abscess. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2010; 43:438-41. [DOI: 10.1016/s1684-1182(10)60067-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 10/02/2009] [Accepted: 10/29/2009] [Indexed: 11/16/2022]
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Byun JL, Bae SH, Park SW. A case of pyogenic liver abscess in a 10-year-old girl. KOREAN JOURNAL OF PEDIATRICS 2010; 53:666-8. [PMID: 21189936 PMCID: PMC2994118 DOI: 10.3345/kjp.2010.53.5.666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 10/08/2009] [Accepted: 10/27/2009] [Indexed: 11/27/2022]
Abstract
Pyogenic liver abscesses are rare in children. In pediatric patients, altered host defences seem to play an important role. However, pyogenic liver abscess also occurs in healthy children. We experienced a case of pyogenic liver abscess in a healthy immunocompetent 10-year-old-girl. The patient presented two distinct abscesses: one subphrenic and the other intrahepatic. The intrahepatic abscess resolved with percutaneous drainage and 3 weeks of parenteral antibiotic therapy but the subphrenic abscess which could not be drained needed prolonged parenteral antibiotic therapy in addition to oral antibiotic therapy. We performed follow-up serial CT scan of the abscess cavity to decide on the duration of antibiotic therapy. Here we present this case with a brief review of the literature.
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Affiliation(s)
- Jung Lim Byun
- Department of Pediatrics, School of Medicine, Konkuk University, Seoul, Korea
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Regalado de los Cobos J, Cía Ruiz JM. Tratamiento del absceso hepático: nueva evidencia de la utilidad de la hospitalización a domicilio. Med Clin (Barc) 2010; 134:486-8. [DOI: 10.1016/j.medcli.2009.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 12/15/2009] [Indexed: 10/19/2022]
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Chiche L, Dargère S, Le Pennec V, Dufay C, Alkofer B. Abcès à pyogènes du foie. Diagnostic et prise en charge. ACTA ACUST UNITED AC 2008; 32:1077-91. [DOI: 10.1016/j.gcb.2008.09.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Revised: 09/04/2008] [Accepted: 09/25/2008] [Indexed: 01/09/2023]
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Freedman J, Guller U, Benjamin DK, Higgins LD, Pan D, Cook C, Pietrobon R. National trends in health care utilization and racial and socioeconomic disparities in pediatric pyogenic arthritis. J Pediatr Orthop 2007; 26:709-15. [PMID: 17065931 DOI: 10.1097/01.bpo.0000229973.78565.02] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine national trends and putative racial and socioeconomic disparities in health care utilization in pediatric patients with pyogenic arthritis over a 13-year period. STUDY DESIGN We assessed trends in length of hospital stay, hospital disposition, and inflation-adjusted charges for pediatric patients hospitalized with pyogenic arthritis based on 13 consecutive years (1988-2000) of the Nationwide Inpatient Sample. Patients with an International Classification of Diseases, Ninth Revision code of pyogenic arthritis were selected for this study. Trends in health care utilization were analyzed, stratified by age, prematurity, joint location, socioeconomic status, and race. RESULTS The median length of stay (LOS) decreased from 10 to 5 days in 1988 and 2000, respectively (P < 0.05). Whites had a shorter mean LOS (7.8 days) than nonwhites (10.7 days; P < 0.05). For both whites and nonwhites, LOS decreased significantly (P < 0.05), but the difference between the 2 groups remained constant. For patients with a higher socioeconomic status, LOS was shorter (P'< 0.05). The percentage of patients discharged to home'health care increased from 3.8% in 1988 to 18.9% in 2000 (P'< 0.05), but the increase was much greater for whites than nonwhites (P < 0.05). Inflation adjusted total charges increased over time, from a median total charge of 10,098 dollars in 1988 to a median total charge of 11,155 dollars in 2000 (P < 0.05). CONCLUSIONS There was a trend toward decreased health care utilization, but no decrease in charges for pediatric pyogenic arthritis from 1988 to 2000. Racial disparities still exist, with little improvement over time.
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Affiliation(s)
- Josh Freedman
- Department of Surgery, Center for Excellence in Surgical Outcomes, Duke University Medical Center, Durham, NC 27710, USA
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Sharara AI, Rockey DC. Pyogenic Liver Abscess. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:437-442. [PMID: 12408780 DOI: 10.1007/s11938-002-0031-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pyogenic liver abscess is an important and often life-threatening disorder. It is commonly caused by underlying disease of the biliary system, but more frequently, no predisposing disorder can be identified. Its diagnosis requires a high index of suspicion and imaging of the liver. The optimal treatment of pyogenic liver abscess is percutaneous drainage and intravenous broad-spectrum antibiotics with activity against enteric aerobic and anaerobic bacteria. Blood and abscess cultures should be obtained and amebic liver abscess carefully eliminated when the diagnosis is in doubt. Surgical drainage, preferably laparoscopic, is reserved for patients with complicated abscesses or after failure of response to initial medical therapy. Possible primary predisposing conditions to pyogenic liver abscess, such as biliary tract disorders, should be sought and managed accordingly. Intravenous antibiotics should be administered for a period of 2 weeks, followed by a more prolonged course of oral antibiotics. The choice and duration of antibiotic therapy, and the need for further intervention are determined by microbiologic data, the patient's clinical response, and repeated imaging studies.
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Affiliation(s)
- Ala I. Sharara
- American University of Beirut, PO Box 11-0236, Department of Internal Medicine, Riad El-Solh, Beirut 1107-2020, Lebanon.
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