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Original Research |
1 All authors: Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.
Received December 17, 2004;
accepted after revision March 23, 2005.
Address correspondence to J. Thomas
(thoma120{at}mc.duke.edu).
Abstract
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MATERIALS AND METHODS. Thirty-three patients with a hepatic abscess treated using percutaneous aspiration and drainage from 1995 to 2000 were identified from a search of the interventional database. The patients' charts and CT images were reviewed independently by two radiologists for clinical presentation, relevant medical history, pre- and postprocedure antibiotic regimens, and clinical course after percutaneous aspiration and drainage. The preprocedure images were reviewed for the location and morphology of the abscess. The procedure details including percutaneous approach, guidance technique, catheter size, and immediate postprocedure complications were reviewed.
RESULTS. Of the 33 patients, 14 patients underwent only needle aspiration of the abscess. In six (43%) of these 14 patients, the abscesses resolved with aspiration and appropriate antibiotic treatment alone. Eight (57%) of the patients who had aspiration of the abscess initially went on to have drainage catheters placed within a 72-hr period. Nineteen patients had drainage catheters placed from the onset. Of these, 17 patients (89%) had abscess resolution. Of the 27 patients who had catheters placed, a total of seven patients (26%) developed clinical symptoms of septicemia after catheter placement, but all patients, at least initially, responded to supportive treatment. Two patients died from septicemia 3-6 weeks after the procedure. None of the patients who underwent aspiration only developed postprocedure septicemia.
CONCLUSION. After placement of a percutaneous drainage catheter in a hepatic abscess, there is a significant risk (26%) of postprocedure sepsis. Although it appears to be a random and unpredictable event in our small series, interventional radiologists and referring physicians should be aware of the risk of sepsis after percutaneous drainage of hepatic abscess.
Keywords: abdomen • abscess • interventional radiology • liver • sepsis
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The patients' charts and electronic medical records were reviewed to evaluate the presenting symptoms, relevant medical history, radiology reports, microbiology results, clinical course, and complications, if any. Two radiologists reviewed the images independently; in cases of disagreement, a consensus was reached after the radiologists jointly reviewed the case. Images were reviewed also to assess the distribution and morphology of the abscesses. In 10 of the patients, the hard-copy films had been purged from the institution's files. In these patients, the information about the distribution and morphology of the abscesses was obtained from radiology reports alone. All procedures were performed in a teaching hospital. The team typically consisted of a senior resident or fellow and an abdominal imaging radiologist. The mean experience of the attending physicians was 7.5 years.
Details about each procedure were recorded including the technique, needle size, and number and size of the catheters used. The patients who initially had needle aspiration only but later returned for catheter placement were also documented. Aspiration needles and single-lumen pigtail catheters were used. Needle sizes of 22-, 20-, and 18-gauge were used in the study. The median needle size was 18-gauge. The catheter sizes were 8-, 10-, 12-, and 14-French. The median catheter size was 12-French.
Patients who had CT- or CT-fluoroscopy-guided drainage were scanned on a single-detector helical CT scanner (CT/i, GE Healthcare). Patients who had sonographically guided aspiration or drainage were scanned with a 3-5-MHz vector probe (Logic 700, GE Healthcare) using a needle guide. Six of the patients for whom placement of an aspiration or drainage catheter had been attempted with sonography guidance subsequently underwent CT-guided aspiration or drainage.
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Twenty-five patients had a single abscess, and eight patients had multiple abscesses. The patients with multiple abscesses were managed with multiple catheters during hospitalization. None of these patients developed postdrainage sepsis. The mean diameter of the abscesses was 4.4 cm (range, 1-15 cm). The majority of the abscesses were in the right hepatic lobe (n = 22). Of the abscesses in the left hepatic lobe, the majority were in the lateral segment (n = 8). All abscesses larger than 1 cm in diameter showed septations and peripheral enhancement. There was no relationship between the distribution and morphology of the abscesses on the likelihood of postdrainage sepsis.
A single organism was isolated from 22 patients, whereas multiple organisms were isolated from 11 patients. Twenty patients had organisms isolated from the abscesses, seven of the patients had organisms isolated only from blood, and three patients had organisms isolated from both blood and the abscess. In the remaining three patients empirically treated with prescribed antibiotics, no organisms were isolated but the patients showed clinical evidence of septicemia. Table 1 details which organisms were isolated. No particular strain of organism was isolated in the patients who developed postdrainage sepsis.
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Thirty patients were on IV antibiotics at the time of the procedure. The working diagnosis for these patients included hepatic abscess (n = 11), postoperative sepsis (n = 8), intraabdominal abscess (n = 3), pneumonia (n = 2), urinary tract infection (n = 2), cholangitis (n = 2), and sepsis secondary to a central line (n = 1) in addition to diverticulitis (n = 1). The most common combination of antibiotics was Unasyn (ampicillin sodium-sulbactam sodium, Pfizer), 3 g IV every 6 hr, and metronidazole, 500 mg IV every 6 hr. Patients who were not already on antibiotics were administered IV antibiotics 1 hr before the procedure. If the patient was already being treated with antibiotics, the next dose was administered immediately before the procedure.
Fourteen patients had needle aspiration of the abscess, and in six of those patients the abscesses resolved with aspiration and IV antibiotic treatment alone. Abscesses that were smaller than 5 cm seemed to best respond to aspiration and antibiotics alone. The remaining eight patients who initially had aspiration of the abscess alone were subsequently referred for placement of drainage catheters. None of these eight patients presented with postdrainage sepsis. Nineteen patients had drainage catheters placed as the initial procedure. The procedure was guided by CT alone in 20 patients, sonography alone in seven patients, and both in six patients.
Procedure-related complications were as follows: one patient developed an empyema secondary to the catheter traversing the pleural space. This complication was treated by thoracoscopic decortication. One patient had a splenic hematoma that subsequently resolved and one patient had hepatic infarction. This patient, however, was lost to follow-up.
Immediate postprocedure sepsis was seen in seven patients. These seven patients had a varied presentation and abscess morphology (Table 2). No difference was seen in the size or number of abscesses or predictors of outcome between the group who developed sepsis and the group who did not develop sepsis. All of these patients were hemodynamically stable when presenting for percutaneous drainage but became septic within 15-30 min after catheter placement. Sepsis was characterized by precipitous development of fever, hypotension, and rigors and in some cases decrease in oxygen saturation. All seven patients subsequently developed respiratory distress and had findings of adult respiratory distress syndrome on portable chest radiographs. Five of these patients subsequently recovered fully with antibiotics and supportive treatment. The mean hospital stay of the seven patients was 14.4 days, which is not significantly different from the mean of 16.5 days that the other patients with catheter placement were hospitalized. The mean hospital stay of the patients who had needle aspiration and antibiotic therapy only was 14 days.
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The two patients who died also showed symptoms of sepsis within 15-30 min after drainage. They too initially responded to resuscitative measures for a short period. However, they died from overwhelming sepsis during the next 2-3 weeks.
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Rae et al. [6] performed percutaneous aspiration alone on 25 patients with hepatic abscesses smaller than 5 cm and had a 100% cure rate. Giorgio et al. [8] reported a 98% cure rate in their series of 115 patients who underwent percutaneous aspiration alone combined with antibiotic therapy. They reported the mean abscess size was 6.8 cm (range, 3-16 cm) and the mean hospital stay was 9 days (range, 7-24 days). In our series, the six patients (43%) who had aspiration alone did not require subsequent catheter placement and recovered without further intervention. In our series, seven (26%) of 27 patients who had abscess drainage with catheters became septic postprocedure despite being on antibiotics. We speculate that sepsis in this setting is likely secondary to overwhelming bacteremia due to intravasation of bacteria directly into the bloodstream.
Because radiologists are often the first physician to encounter the patient with postprocedure sepsis, they have a vital role. Supportive measures should be initiated as soon as the patient shows chills, rigors, and fever, which are often the first signs of sepsis. Treatment— including IV antibiotics, fluid volume resuscitation, high-flow oxygen, and, if necessary, vasopressors such as dopamine—should be initiated, the referring service should be informed, and initiation of intensive care should be arranged.
In patients who become septic despite prophylactic antibiotics, it is reasonable to empirically administer an antibiotic with a different spectrum of coverage, although this approach has not been substantiated in the literature. It is also reasonable to commence volume resuscitation by administering a challenge of 500-1,000 mL of crystalloid solution if not contraindicated (e.g., poorly controlled congestive heart failure).
The old adage "Prevention is better than cure" holds true in the setting of hepatic abscess drainage. Aside from preprocedure antibiotics, the most important preventive measure is to avoid excessive manipulation of the infected fluid [9, 10]. Manipulation, including overdistention by injecting saline or contrast material into the abscess, is associated with an increased risk of sepsis, as has been shown by Mueller et al. [11], Lang and Price [12], and Thomas [13]. Indeed, one of our patients became septic after flushing of the catheter after placement.
Operator experience can play a role in the incidence of postdrainage sepsis. Oberholzer et al. [14] performed a retrospective review of 1,000 biliary procedures over a 16-year period and found that operator experience was associated with a decline in the rate of sepsis from 1.9% to 0.5%. Although one could infer the difference was due to technical advancements and operator experience, the authors acknowledge that a change in patient population and referral patterns may have played a role.
A number of authors have attempted to correlate sepsis with patient presentation. It is intuitive that the patient who is septic before the procedure may worsen during and after the procedure. The cause of the abscess may play a role. Indeed, Cohan et al. [15] have shown that, at least with biliary procedures, sepsis is more likely to occur in the setting of malignant obstruction. In our series, all the patients who had sepsis after drainage showed signs of infection at the time of the intervention. The two patients who died had multiple comorbid conditions. However, both patients decompensated hemodynamically shortly after percutaneous drainage.
In our series, no clinical features could be identified to predict the development of postprocedure sepsis; specifically, no correlation was drawn with the incidence of postprocedure sepsis and the patients' presenting symptoms or medical history or the distribution and morphology of the hepatic abscesses.
Although this is a retrospective study with a limited number of patients, a few important conclusions can be drawn from the study. Postprocedure sepsis after drainage does occur despite the preprocedure administration of antibiotics. In our series, sepsis occurred in 26% of patients. Although postprocedure sepsis appears to be unpredictable and random in our experience, it does occur and it is important to initiate timely treatment. Referring physicians and interventional radiologists should be aware of the real possibility of postprocedure sepsis. Further prospective research in this area is warranted.
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