Pyogenic Liver Abscess: Recent Trends in Etiology and Mortality
Joseph Rahimian,1 Tina Wilson,2 Valerie Oram,1 and Robert S. Holzman1
School of Medicine and 2Downtown Hospital, New York University, New York
Background. Pyogenic liver abscess, a potentially life-threatening disease, has undergone signiﬁcant changes in epidemiology, management, and mortality over thepast several decades. Methods. We reviewed the data for patients admitted to Bellevue Hospital and New York University Downtown Hospital (New York, New York) over a 10-year period. Results. Of 79 cases reviewed, 43% occurred in patients with underlying biliary disease. The most common symptoms were fever, chills, and right upper quadrant pain or tenderness. The most common laboratory abnormalitieswere an elevated white blood cell count (in 68% of cases), temperature 38.1 C (90%), a low albumin level (70.2%), and an elevated alkaline phosphatase level (67%). Seventy percent of the abscesses were in the right lobe, and 77% were solitary. Klebsiella pneumoniae was identiﬁed in 41% of cases in which a pathogen was recovered. Eighteen (50%) of 36 Asian patients had K. pneumoniae isolated, incontrast to 6 (27.3%) of 22 non-Asian patients (not statistically signiﬁcant). Fifty-six percent of cases involved treatment with percutaneous drainage. Although prior reports noted mortality of 11%–31%, we observed only 2 deaths (mortality, 2.5%). Conclusions. The data suggest that K. pneumoniae has become the predominant etiology of pyogenic liver abscess and that mortality from this disease hasdecreased substantially. Pyogenic liver abscess (PLA) was reported in the writings of Hippocrates, who based prognosis on the type of ﬂuid recovered from the abscess . In 1938, Ochsner and DeBakey  described the treatment and mortality of patients with PLA and recommended surgical treatment as the primary treatment modality. At that time, PLA was most commonly a complication of acuteappendicitis, occurred predominantly in young men, and was associated with high mortality. Surgery remained the therapy of choice until the mid 1980s, when percutaneous drainage was shown to be a safer alternative in many cases [3–6]. Mortality rates have decreased substantially over the past several decades, with recent studies reporting rates of 11%–31%. The mean age of patients with PLA hasincreased, and the most common cause reported in recent series has shifted to biliary disease [5–10]. In reports from the United States, the most common organism recovered from patients in the United States has been Escherichia coli [4–6, 11], although one study found Klebsiella pneumoniae to be predominant [7, 12]. Recent reports from Taiwan have described an increase in the rate of PLA due to K.pneumoniae, which, in one series, was recovered from 82% of patients . Because such experiences have not yet been reported in the United States, we reviewed the cases of PLA seen at our institutions over the past decade. METHODS Bellevue Hospital is a 900-bed municipal hospital in Manhattan (New York). New York University (NYU) Downtown Hospital is a 140-bed community hospital, also located inManhattan (New York), near to New York’s Chinatown district. This study was approved by the institutional review boards of the participating hospitals. All 171 cases involving inpatients who received a discharge diagnosis of PLA from January 1993 through December 2003 from either Bellevue Hospital or NYU Downtown Hospital were eligible for inclusion. Cases were included if the abscess was conﬁrmed byimaging as well as by either documentation of an organism re-
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Received 22 June 2004; accepted 29 July 2004; electronically published 9 November 2004. Presented in part: 42nd Meeting of the Infectious Diseases Society of America, Boston, Massachusetts, 30 September–3 October, 2004 [abstract 400].. Reprints or...