さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

肝膿瘍

消化器の先生から「肝膿瘍」の相談をいただきました。

 

重症例、Sepsis shockを疑う、 ドレナージ不可、血培2セット提出済

 

Up To Dateで復習してみました。

 

起因菌

 

The Streptococcus milleri or S. anginosus group (including S. constellatus and S. intermedius) is an important cause of liver abscess. 

 

S. aureus, S. pyogenes, and other Gram positive cocci are recognized pathogens in specific circumstances. 

 

Candida species have also been implicated in pyogenic liver abscess and accounted for 22 percent of liver abscesses in one series . 

 

Klebsiella pneumoniae is an important emerging pathogen. This syndrome is discussed in detail separately.

 

Tuberculous liver abscesses are uncommon but should be considered when typical pyogenic organisms are not recovered from cultures. 

 

Burkholderia pseudomallei (the agent of Melioidosis) should be considered in patients from endemic areas (Southeast Asia and Northern Australia). 

 

Amebiasis should be considered as a cause of primary liver abscess, especially in patients who are from or have traveled to an endemic area within the past six months. The clinical course and appearance may be difficult to distinguish from pyogenic liver abscess; this is discussed in detail separately.

 

抗菌薬

Firstは、以下の内容、血液培養の結果判明後、De-escalationを考慮

Up To Dateより引用

First choice
Monotherapy with a beta-lactam/beta-lactamase inhibitor:
Ampicillin-sulbactam 3 g IV every six hours
Piperacillin-tazobactamΔ 3.375 or 4.5 g IV every six hours
Ticarcillin-clavulanate 3.1 g IV every four hours
Combination third generation cephalosporin PLUS metronidazole:
Ceftriaxone plus 1 g IV every 24 hours or 2 g IV every 12 hours for CNS infections
Metronidazole

500 mg IV every eight hours

 

治療期間

ドレナージできない場合は、抗菌薬点滴で4から6週間。

patients with incomplete drainage should receive four to six weeks of parenteral therapy

 

毎回の悩みは、その後の内服薬スイッチ。。。

 

 If culture results are not available, reasonable empiric oral antibiotic choices includeamoxicillin-clavulanate alone or a fluoroquinolone (ciprofloxacin or levofloxacin) plus metronidazole.

 

 

現実は、6週入院が難しいため、

抗菌薬の点滴で膿瘍縮小が見られなくなった後に、上記の内服薬にスイッチし膿瘍の拡大がなければ、退院し外来フォローかな。

 

ドレナージできない症例が多く、いろいろと難しいですね


それでは、 重要な

Klebsiella pneumoniae primary liver abscess (KLA) についてUpToDate から復習


 Klebsiella pneumoniae primary liver abscess (KLA) occurs in the absence of hepatobiliary disease and is almost always monomicrobial. Most cases have been reported from Asia or in patients of Asian origin.


 Diabetes mellitus or impaired fasting glucose is the most important host risk factor for primary KLA.


The Klebsiella isolates that cause KLA have an increased number of virulence factors compared with other Klebsiella isolates and appear to be restricted geographically. 


In addition to the manifestations typical of pyogenic liver abscess, such as fever, leukocytosis, right upper quadrant tenderness, and elevated liver enzymes, a minority of patients with primary KLA can develop metastatic infections at other sites. The most common sites for metastatic infections are the eye, meninges, and brain. 


Imaging should be performed in patients with signs and symptoms of a liver abscess or in patients with Klebsiella pneumonia bacteremia who have persistent fevers despite appropriate antibiotic therapy. Diagnosis of primary KLA is made by detection of a liver abscess on imaging (ultrasound or computed tomography [CT]) followed by aspiration of the lesion for Gram stain and aerobic and anaerobic culture.


Treatment of KLA requires parenteral antibiotic therapy in addition to drainage, optimally percutaneous. Antibiotic choice should be based upon the results of antibiotic susceptibility testing. A third-generation cephalosporin is preferable if the isolate is susceptible and cost is not prohibitive. Antibiotics should be given for at least four to six weeks, depending on abscess resolution as determined by imaging findings.


The reported mortality rate has ranged from 4 to 11 percent. Metastatic disease to the eyes or brain can cause significant long-term morbidity.