Pyogenic Liver Abscess Audit

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Background

Pyogenic liver abscess (PLA) is a serious but rare clinical entity carrying a mortality rate of up to 19%.  Readily available access to increasingly sophisticated imaging modalities has made diagnosing PLA easier, however the optimal management of PLA remains controversial and may ultimat
ely depend on local facilities and expertise.

The last two decades have seen a paradigm shift in the management of PLA towards interventional drainage and long term intravenous antibiotics, with traditional surgical approaches being reserved for refractory cases.

The majority of the published literature on the aetiology, microbiology and developing management of PLA originates from Asian centres where hepatic lesions are more prevalent. The largest series to date (483 patients) was reported by Chou et al in 1997.  The majority of Asian reports advocate the use of percutaneous aspiration of PLA with IV antibiotics and reserve surgery only for acute emergencies or salvage cases. The largest western study reports from a single centre in France. They reviewed the management of 103 patients with PLA and the authors were strong proponents of early surgical intervention in patients with severe sepsis, gas forming organisms, and multi-loculated abscesses.

At present there has been no formal systematic review of the management of PLA in the UK and no national guidelines for the management of PLA exist. To our knowledge this is the first regional review of the management of PLA in the UK.

Study Question

How are pyogenic liver abscesses managed and what are the outcomes in the Mersey region?

Study Aim

To establish how PLA’s are managed regionally and establish the regional outcomes

Using data obtained from this study and systematic review together with local expertise; formulate guidelines to aid management of PLA.

Study Design

Initial regional retrospective audit of all cases managed between January 2015 and December 2016 in the Mersey region.

Parallel systematic review of literature with view to developing national guidelines for the management of pyogenic liver abscesses.

Outcomes

Primary

  • Time to resolution of the PLA
  • Defined: time from diagnosis (radiological) to time of clinical (and or radiological) resolution of abscess

Secondary

  • Length of stay (defined date of admission to date of discharge)
  • Readmission rate (defined: all readmissions within 30 days of discharge)
  • 30, 60, 90 day and in-hospital mortality
  • Patient demographics (age, gender, presenting complaint, DM, cirrhosis)
  • Location, size and number of abscesses
  • Treatment:
  • Interventional treatment (defined: IR drainage/ drain insertion or aspiration)
  • Requirement for surgical intervention (defined: open or laparoscopic surgical intervention for the PLA)
  • Length of stay in critical care (defined: time spent in level 2/3 facility)
  • Microbiology results (defined: Microorganism/s responsible. Source of positive result BC,aspirate)
  • Medical speciality in charge of patients care (Defined: Medical / Surgical)
  • Antibiotic give, route of administration and length of course (IP or OP)
  • Referral to tertiary liver centre / transfer of patient
  • Follow up imaging to monitor PLA progress (defined: type, date / frequency of all surveillance imaging of PLA including USS, MRI, CT and PET)
  • Complication rate (defined by Clavien-Dindo classification)
  • Cause of PLA (defined: aetiology. E.g diverticular disease, appendicitis, crohns, colorectal cancer,etc)

Steering Group

Name Role
Prof Ghaneh Academic Co-Lead, Consultant HPB surgeon
Mr Halloran Academic Co-Lead, Consultant HPB surgeon
Ms Andrea Sheel LTRC Co-Chair
Mr Kulbir Mann LTRC Co-Chair
Mr Declan Dunne Aintree Lead
Ms Vicky Fretwell RLUH Lead
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