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CHARACTERISTICS OF PATIENTS AND RESULTS OF ERYTHROMYCIN

OR PLACEBO TREATMENT OF CAMPYLOBACTER ENTERITIS

Discussion

As more diagnostic microbiology laboratories haveinstituted routine procedures for the isolation of C. jejunifrom stool specimens, the importance of this microorganismas an enteric pathogen has grown. The clinical features of theillness caused by C. jejuni have been described well in bothadults4,6 and children.7,11 The illness appears to be self-limited in normal hosts, with recovery occurring in 7-10days. Stool carriage of the organism generally persists for 2-5weeks. b

It is often claimed that erythromycin favourably alters thecourse of campylobacter infections in certain cases,3,4,7,12 butno placebo-controlled trials have been reported. Becauseerythromycin may cause gastrointestinal side-effects that canbe severe and because antimicrobial treatment results in

prolonged stool carriage without ameliorating the course ofthe disease in salmonella gastroenteritis,13 we felt that it wasimportant to investigate erythromycin treatment of

campylobacter enteritis in a double-blind trial.The efficacy of erythromycin in eradicating C. jejuni from

the stool was dramatic. All patients in the erythromycingroup had negative stool cultures one week later, including 2patients who took the drug for only 2 days. It is possible thatless than 5 days of treatment might be equally efficacious ineffecting a bacteriological cure.We were unable, however, to show a beneficial effect of

erythromycin treatment on the clinical course of

campylobacter enteritis. Possibly earlier treatment wouldhave been effective. In our experience the diagnosis often isnot confirmed until 5-7 days after onset of illness, by whichtime many patients have already started to improve.

It seems clear that most patients with campylobacterenteritis will recover without specific antibiotic therapy.Because person-to-person transmission can occur, however,it is reasonable to treat some patients with erythromycin tohasten bacteriological cure and to limit transmission. Inparticular, children in day-care centres, health care workers,and food handlers should be treated. Moreover, whensymptoms have been prolonged, bloody diarrhoea is severe,or relapses occur, treatment seems prudent. In each case thebenefits of treatment need to be weighed against the side-effects of erythromycin.

We thank Mr Stanley Mirrett, Ms Marti Roe, Ms Linda Kahler, and thetechnologists of the microbiology laboratories for their help in promptlyidentifying patients with campylobacter enteritis, and Ms C. Hudspeth fortyping the manuscript. This study was supported in part by a grant from theUpjohn Company, Kalamazoo, Michigan.

Correspondence to: B. J. A., Box C227, University of Colorado HealthSciences Center, 4200 E. 9th Avenue, Denver, Colorado 80262, U.S.A.

REFERENCES

1. Blaser MJ, Reller LB. Campylobacter enteritis. N Engl J Med 1981; 305: 1444-52.2. Butzler JP, Dekeyser P, Detrain M, Dehaen F. Related vibrio in stools. J Pediatr 1973;

82: 493-95.3. Skirrow MB. Campylobacter enteritis: a "new" disease. Br Med J 1977; ii: 9-11.4. Blaser MJ, Berkowitz ID, LaForce FM, Cravens J, Reller LB, Wang W-LL

Campylobacter enteritis: Clinical and epidemiologic features. Ann Intern Med 1979,91: 179-85.

5. Vanhoof R, Vanderlinden MP, Dierickx R, Lauwers S, Yourassowsky E, Butzler JP.Susceptibility of Campylobacter fetus subsp jejuni to twenty-nine antimicrobialagents. Antimicrob Ag Chemother 1979; 14: 553-56.

6. Butzler JP, Skirrow MB. Campylobacter enteritis. Clin Gastroenterol 1979; 8: 737-657. Karmali MA, Fleming PC. Campylobacter enteritis in children. J Pediatr 1979; 94:

527-33.8. Paisley JW, Mirrett S, Lauer BA, Roe M, Reller LB. Darkfield microscopy of human

feces for the presumptive diagnosis of Campylobacter enteritis. J Clin Microbiol1982; 15 (in press).

9. DiSanto AR, Chodos DJ. Influence of study design in assessing food effects onabsorption of erythromycin base and erythromycin stearate. Antimicrob AgChemother 1981; 20: 190-96.

10. Eriksson M, Bolme P, Blennow M. Absorption of erythromycin from pediatricsuspension in infants and children. Scand J Infect Dis 1981; 13: 211-15.

11. Pai CH, Sorger S, Lackman L, Sinai RE, Marks MI. Campylobacter gastroenteritis inchildren. J Pediatr 1979; 92: 589-91.

12. Lambert ME, Schofield PF, Ironside AG, Mandal BK. Campylobacter colitis. BrMedJ 1979; i: 857-59.

13. Nelson JD, Kusmiesz H, Jackson LH, Woodman E. Treatment of Salmonellagastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:125-30.

TREATMENT OF PYOGENIC LIVER ABSCESSESBY PERCUTANEOUS NEEDLE ASPIRATION

LESLIE A. BERGER DAVID R. OSBORNE

Department of Diagnostic Radiology and Academic Departmentof Surgery, Royal Free Hospital, and

Royal Free Hospital School of Medicine, London NW3 2QG

Summary Fifteen patients with solitary or multiplepyogenic liver abscesses diagnosed by ultra-

sound examination were treated by percutaneous aspirationunder ultrasound guidance. The pus obtained was culturedimmediately for aerobic and anaerobic organisms and

appropriate antibiotic therapy was started. Anaerobic

organisms were grown from this pus in nine patients. Allpatients improved after the aspiration and, apart from furtheraspirations in two cases, all abscesses healed without furtherintervention. No patient died from liver abscess or as a resultof treatment. The technique is simple and harmless and is themethod of choice for diagnosing and treating patients withpyogenic liver abscesses.

Introduction

THE management of pyogenic liver abscesses has changedlittle in the past forty years, despite advances in techniques ofinvestigation and in antibiotic therapy. Diagnosis may bemissed until necropsy because of the non-specific nature ofthe clinical course. Established surgical teaching advocatescomplete drainage at surgery, but mortality and morbidityremain high.2,3 Percutaneous aspiration is accepted in themanagement of amoebic liver abscesses but not for pyogenicliver abscesses. We report fifteen consecutive cases of

pyogenic liver abscess treated by needle aspiration underultrasound guidance and by appropriate antibiotic therapy.

Patients and Methods

We treated liver abscesses in twelve men and three women agedfrom 21 to 76, with a mean of 47 years, by percutaneous aspiration.

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Ten patients had a solitary liver abscess, nine in the right lobe andone in the left lobe. In five patients the abscesses were multiple.In four patients the abscesses followed surgery: in one patient for

gallstones, in one for carcinoma of the pancreas, in one forcarcinoma of the stomach, and one patient underwent an emergencycolectomy for ulcerative colitis. Four patients had diseases of thebowel-i.e., acute ulcerative colitis, diverticulitis, acute

appendicitis-and one had recently had her haemorrhoids injected.In two patients a secondary pyogenic infection had probablydeveloped in an amoebic abscess since their amoebic antibody testswere positive. One patient had carcinoma of the pancreascomplicated by metastases and cholangitis. In four patients nosource of infection could be identified.The symptoms were mainly non-specific with general lassitude

and malaise as the most common features (fifteen patients). Ninehad right upper quadrant discomfort, seven had nausea and

vomiting, six had weight loss, and two had pleural effusions. Somepatients had had symptoms for many months before a diagnosis wasmade, especially the patients in whom there was no recognisablesource of infection. Pyrexia with rigors developed in the course ofthe illness in all, but blood cultures were only positive in twopatients. However, eight were on antibiotic therapy at the time.Eleven patients had an enlarged liver, which was tender in nine. Infourteen patients the erythrocyte sedimentation rate was markedlyraised, thirteen had a leucocytosis and twelve were anaemic.Although only three patients were jaundiced, seven had raisedserum concentrations of liver enzymes.

ManagementAll patients were examined by one of us (L.A.B.) using a

Disonograph 4102B or Emisonic 4200 with grey-scale attachment.When an abscess was found its surface markings were mapped outand the depth of the wall closest to the surface was measured. Afterinfiltration of the abdominal wall and peritoneum with localanaesthetic an 18, 19, or 21 gauge needle was inserted whilst thepatient held his breath. The needle was connected by an extensiontube to a 60 ml syringe. Solitary abscesses were aspirated ascompletely as possible but only a few of the largest multiple lesionswere treated. The pus was cultured immediately for aerobic andanaerobic organisms. Antibiotic therapy had already been started ineight patients and this was corrected where necessary once cultureand antibiotic sensitivity had been determined. In several instancestreatment was started within the first 24 h of hospital stay. Mostsolitary abscesses were large, with a volume of 100 to 200 mlremoved by aspiration. The largest was 350 ml.

Results

Immediately after aspiration of a solitary abscess all

patients felt better, their pyrexia and tachycardia resolved bycrisis, their appetite returned, and their haemoglobinconcentration rose. Subsequent scanning demonstrated rapidhealing of the cavity except in one patient who required asecond aspiration before the abscess finally resolved. Thelargest abscess measured one sixth of its original volume 4weeks after aspiration and had completely healed when thepatient was re-examined at 6 months.In the patients with multiple abscesses the largest two or

three abscesses only were aspirated at presentation. Onepatient subsequently underwent two further aspirationswithout distress. All patients improved steadily on

appropriate antibiotic therapy, though at a somewhat slowerrate than the patients with a solitary abscess. Serial scans wereused to assess progress. In the most severely affected patient10 months elapsed before her liver appeared normal at

ultrasonography. After aspiration the average stay in hospitalfor patients with a solitary abscess was 11 days and forpatients with multiple abscesses it was 20 days. All were wellwhen discharged from hospital and in a follow-up period of 1

to 4 years there have been no recurrences. The patient withliver metastases died from his cancer after 3 months.

BacteriologyIn five patients only one organism was grown, six patients

had a mixed growth, and in four the pus was sterile onculture.

Anaerobic organisms sensitive to metronidazole werecultured in nine patients. A more detailed report of thebacteriology of liver abscesses has appeared elsewhere.4

Discussion

An untreated pyogenic liver abscess is usually fatal. Opensurgical drainage and antibiotics have improved the

prognosis,3 but after such treatment 13-21 % of patients witha single abscess and 77% of patients with multiple abscessesdie from their disease. 1,2The diagnosis and precise localisation of liver abscesses was

a problem, despite the use of isotopic liver scan, until theadvent ofuntrasound scanning. Ultrasound scanning is bothharmless and accurate in these ill patients and it locates anabscess so precisely that it can be drained at once bypercutaneous needle puncture and pus can be obtained forculture. The correct antibiotic regimen can then be

instituted.We experienced no difficulty in demonstrating solitary or

multiple abscesses so that neither hepatic arteriography norcomputerised tomography scanning was required. It may bedifficult to distinguish multiple liver abscesses from

secondary deposits by appearances alone but needle

aspiration under ultrasound guidance of one of these lesionswill readily make this distinction. If a secondary is puncturedthen the aspirate is sent for cytology. There was no difficultyin differentiating an abscess from a hydatid cyst since theirappearances at ultrasound examination are dissimilar.Needle aspiration of pyogenic liver abscesses is not a new

technique. In 1953 McFadzean reported the aspiration offourteen pyogenic abscesses by means of a 14 gauge needle ortrocar and cannula.s He injected streptomycin and penicillininto the cavity at the end of the aspiration. Antibiotics wereprescribed only when organisms were grown from the pus. Acure was achieved in all patients.5 However, the techniquewas not generally accepted. Since then there have been

reports of three abscesses aspirated at laparotomy, of sixpatients treated by antibiotics alone,’ and of sixteen patientstreated by percutaneous insertion of a drainage catheter. 8-10We have found that needle aspiration followed by theappropriate antibiotic regimen is simple and effective andthat no complications developed, although further aspirationwas necessary occasionally.

Patients with multiple liver abscesses are acutely ill andhave a high mortality rate with conventional therapy. It wasimpractical to attempt to drain all the abscesses initially butafter drainage of the larger ones and appropriate antibiotictherapy the patients’ condition improved. This improvementallowed any residual collections to be aspirated later.

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We believe that early diagnosis by ultrasound scanning, asthe first investigation, followed by needle aspiration andantibiotics is the treatment of choice for patients withpyogenic liver abscesses.We thank all the doctors who referred patients to us, particularly Prof. Sheila

Sherlock, D.B.H. We thank Prof. K. E. F. Hobbs for his help andencouragement. Miss Amanda Gerroll typed the article.

Correspondence should be addressed to L. A. B., Department of Radiology,Royal Free Hospital, London NW3 2QG.

REFERENCES

1 Heyman AD. Clinical aspects of grave pyogenic abscesses of the liver. Surg GynecolObstet 1979; 149: 203-13.

2. Satiani B, Davidson ED. Hepatic abscesses: Improvement in mortality with earlydiagnosis and treatment. Am J Surg 1978; 135: 647-50.

3 Pitt HA, Zuidema GD. Factors influencing mortality in the treatment of pyogenichepatic abscess. Surg Gynecol Obstet 1975; 140: 228-34.

4. Perera MR, Kirk A, Noone P. Presentation, diagnosis and management of liver abscess.Lancet 1980; ii: 629-32.

5. McFadzean AJS, Chang KPS, Wong CC. Solitary pyogenic abscess treated by closedaspiration and antibiotics: fourteen consecutive cases with recovery. Br J Surg 1953;41: 141-52.

6. Patterson HC. Open aspiration for solitary liver abscess. Am J Surg 1970; 119: 326-29.7. Maher JA, Reynolds TB, Yellin AE. Successful medical treatment of pyogenic liver

abscess. Gastroenterology 1979, 77: 618-22.8 Kraulis JE, Bird BL, Colapinto ND. Percutaneous catheter drainage of liver abscess an

alternative to open drainage? Br J Surg 1980; 67: 400-2.9. Gerzof SG, Robbins AH, Johnson WJ, Berkett DH, Nabseth DC. Percutaneous

catheter drainage of abdominal abscess-a five-year experience. N Engl J Med 1981;305: 653-57.

10. Martin EC, Karlson KB, Fankuchen E, Cooperman A, Casarella WJ. Percutaneousdrainage in the management of hepatic abscess. Surg Clin N Am 1981; 61: 157-67.

PYOGENIC LIVER ABSCESSES: SUCCESSFULNON-SURGICAL THERAPY

DAVID A. HERBERT

JEFFREY ROTHMANFRED SIMMONS

DAVID A. FOGELSAMUEL WILSON

JOEL RUSKINDivisions of Infectious Disease and Hepatology, Department of

Internal Medicine, Kaiser-Pemanente Medical Center, Los Angeles,California; and Department of Medicine, University of California

School of Medicine, Los Angeles, California, U.S.A.

Summary Eleven consecutive patients with pyogenicliver abscesses were seen in a 20-month

study period. Ten patients were treated with antibioticsalone. All ten had abscesses demonstrated by hepaticscintigraphy or sonography. In six patients purulent materialwas obtained by percutaneous aspiration of the liver. Blood-cultures were positive in each of the nine patients in whomthey were obtained. Nine of the ten patients treated withantibiotics alone were cured; one died from complications of aliver biopsy. These results indicate that pyogenic liverabscesses can be effectively managed by medical therapy andthat surgery is rarely required.

Introduction

SURGICAL drainage is widely regarded as an essentialcomponent in the management of pyogenic liverabscesses. 1-15 However, our favourable experience withmedical management in a patient with a solitary abscess whorefused surgery and the similar experience of others8prompted us to question the necessity of surgicalintervention. We have conducted a trial of antibiotic therapywithout surgical drainage in patients admitted to our

institution with pyogenic liver abscesses.

Patients and Methods

All patients with the diagnosis of pyogenic liver abscess admittedto the Kaiser-Permanente Medical Center in Los Angeles from

August, 1979, through April, 1981, were included in the study.Each patient was seen by one or more ofus; a retrospective review ofall admissions during that period confirmed that we had seen everypatient at our institution with this diagnosis.

Patients were considered to have had pyogenic liver abscess if allthe following criteria were satisfied:

(1) Hepatic scintiscanning revealed one or more filling defects, orhepatic sonograms showed one or more areas of echolucency (ormixed echolucency and reflection), and there were no other causesfor these lesions.

(2) Amoebic serology (’Serameba’, Ames Laboratories, Elkhart,Indiana) was negative.

(3) Purulent material was obtained at percutaneous aspiration ofthe liver, and/or cultures of blood were positive in the absence ofextrahepatic sources of infection.

Patients were considered to have responded to therapy if all the’following occurred: (1) temperature and leucocyte count becamenormal (if initially raised), (2) abdominal pain resolved, (3) repeatsonograms or radionuclide scans showed definite shrinkage or

resolution of the hepatic lesion(s), (4) no signs or symptoms ofrecurrent abscess at follow-up examinations.

Nuclear scans were performed after the intravenous injection ofeither 3 mCi of technetium-99m (Tc-99m) sulphur colloid or of 2-5mCi of Tc-99m-labelled N-(2,6-dimethylphenylcarbamoylmethyl)aminodiacetic acid. At least three views of the liver were obtained tooptimise the detection of filling defects. Sonography was performedwith a Rohe sonogram, used with either a 3 - 6 MHz or a 5 MHztransducer. Percutaneous aspiration of the liver was performedunder local anaesthesia by means of a 22-gauge needle. In one case,peritoneoscopy was used to direct the aspiration.

Blood was cultured in aerobic and anaerobic media and growthwas detected radiometrically (’Bactec’ system, JohnsonLaboratories, Cockesville, Maryland). Subcultures were made fromthe aerobic bottle after one day of incubation and from the anaerobicbottle on the third day of incubation. Pus from aspiration of theabscesses was either inoculated into ’blood-culture bottles and

processed as described or was plated on conventional aerobic andanaerobic media. Antimicrobial susceptibility testing was

performed by the Kirby-Bauer disc diffusion method.

Results

Pyogenic liver abscess was diagnosed in eleven patientsduring the 20 months of the study. Ten patients who weremanaged without drainage of their abscesses form the basis ofthis report. One patient, whose physician preferredimmediate surgical drainage without a trial of medical

management, was excluded from the study.The clinical characteristics of our ten patients with

medically treated pyogenic liver abscesses and the means bywhich they were diagnosed are shown in table I. There wereeight men and two women; their average age was 59 years. Allbut two patients had identifiable underlying diseases thatmay have contributed to the development of a pyogenic liverabscess. Three had hepatobiliary abnormalities includingcholelithiasis, cholecystitis, and cirrhosis from schistoso-miasis. Colon carcinoma was discovered in one patient 2months after the abscess resolved. Four had diabetes. One

patient had Job’s syndrome, a poorly understood immu-nological deficiency that predisposes to recurrent staphyl-ococcal infections.

All ten patients initially had fever and abdominal pain.Seven had leucocytosis. A consistent pattern of abnormal