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      Liver abscess: diagnostic and management issues found in the low resource setting


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          Liver abscesses are mainly caused by parasitic or bacterial infection and are an important cause of hospitalization in low-middle income countries (LMIC). The pathophysiology of abscesses is different depending on the etiology and requires different strategies for diagnosis and management. This paper discusses pathophysiology and epidemiology, the current diagnostic approach and its limitations and management of liver abscess in low resource settings.

          Sources of data

          We searched PubMed for relevant reviews by typing the following keywords: ‘amoebic liver abscess’ and ‘pyogenic liver abscess’.

          Areas of agreement

          Amoebic liver abscess can be treated medically while pyogenic liver abscess usually needs to be percutaneously drained and treated with effective antibiotics.

          Areas of controversy

          In an LMIC setting, where misuse of antibiotics is a recognized issue, liver abscesses are a therapeutic conundrum, leaving little choices for treatment for physicians in low capacity settings.

          Growing points

          As antimicrobial resistance awareness and antibiotic stewardship programs are put into place, liver abscess management will likely improve in LMICs provided that systematic adapted guidelines are established and practiced.

          Areas timely for developing research

          The lack of a quick and reliable diagnostic strategy in the majority of LMIC makes selection of appropriate treatment challenging.

          Related collections

          Most cited references29

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          Community-Acquired Klebsiella pneumoniae Bacteremia: Global Differences in Clinical Patterns

          We initiated a worldwide collaborative study, including 455 episodes of bacteremia, to elucidate the clinical patterns of Klebsiella pneumoniae. Historically, community-acquired pneumonia has been consistently associated with K. pneumoniae. Only four cases of community-acquired bacteremic K. pneumoniae pneumonia were seen in the 2-year study period in the United States, Argentina, Europe, or Australia; none were in alcoholics. In contrast, 53 cases of bacteremic K. pneumoniae pneumonia were observed in South Africa and Taiwan, where an association with alcoholism persisted (p=0.007). Twenty-five cases of a distinctive syndrome consisting of K. pneumoniae bacteremia in conjunction with community-acquired liver abscess, meningitis, or endophthalmitis were observed. A distinctive form of K. pneumoniae infection, often causing liver abscess, was identified, almost exclusively in Taiwan.
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            Primary liver abscess due to Klebsiella pneumoniae in Taiwan.

            Pyogenic liver abscess is an uncommon complication of intra-abdominal or biliary tract infection and is usually a polymicrobial infection associated with high mortality and high rates of relapse. However, over the past 15 years, we have observed a new clinical syndrome in Taiwan: liver abscesses caused by a single microorganism, Klebsiella pneumoniae. We reviewed 182 cases of pyogenic liver abscess during the period September 1990 to June 1996; 160 of these cases were caused by K. pneumoniae alone, and 22 were polymicrobial. When patients with K. pneumoniae liver abscess were compared with those who had polymicrobial liver abscess, we found higher incidences of diabetes or glucose intolerance (75% vs. 4.5%) and metastatic infections (11.9% vs. 0) and lower rates of intra-abdominal abnormalities (0.6% vs. 95.5%), mortality (11.3% vs. 41%), and relapse (4.4% vs. 41%) in the former group. Liver abscess caused by K. pneumoniae is a new clinical syndrome that has emerged as an important infectious complication in diabetic patients in Taiwan.
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              Population-based study of the epidemiology of and the risk factors for pyogenic liver abscess.

              Pyogenic liver abscess (PLA) is relatively uncommon in North America but is associated with significant morbidity and mortality. Our objective was to characterize the incidence of, risk factors for, and outcomes of PLA in a nonselected population. Population-based surveillance was conducted in the Calgary Health Region (CHR) between April 1, 1999 and March 31, 2003. All adult CHR residents with PLA were identified, and charts were reviewed. Seventy-one CHR residents developed a PLA for an annual incidence of 2.3 per 100,000 population. There was an increasing incidence of PLA with advancing age. Men were at much higher risk of acquiring a PLA as compared to women (3.3 vs 1.3 per 100,000; relative risk [RR], 2.6; 95% confidence interval [CI], 1.5-4.6; P < .001), and this was observed across all age groups. A number of comorbid conditions were associated with significantly higher risk for developing a PLA including liver transplantation patients (RR, 444.8; 95% CI, 89.5-1356.0; P < .0001), diabetics (RR, 11.1; 95% CI, 6.3-19; P < .0001), and patients with a history of malignancy (RR, 13.3; 95% CI, 6.9-24.4; P < .0001). No other solid organ transplantation patient was at increased risk. All patients required admission to hospital (median length of stay, 16 days), and 7 (10%) patients died in hospital, corresponding to a mortality rate of 0.22 per 100,000 population. This study provides important data on the burden of PLA and identifies risk groups that might potentially benefit from preventive efforts.

                Author and article information

                Br Med Bull
                Br. Med. Bull
                British Medical Bulletin
                Oxford University Press
                December 2019
                13 December 2019
                13 December 2019
                : 132
                : 1
                : 45-52
                [1 ] Diagnostic Microbiology Development Program , 12152, Phnom-Penh, Cambodia
                [2 ] Siem Reap Referral Hospital , 17252, Siem Reap, Cambodia
                Author notes
                Correspondence address. E-mail: gaetan.khim@ 123456dmdp.org .
                © The Author(s) 2019. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                : 12 April 2019
                : 29 August 2019
                : 16 September 2019
                : 16 September 2019
                Page count
                Pages: 8
                Invited Review

                liver abscess,amoebic,pyogenic,resource limited settings,low-middle income countries
                liver abscess, amoebic, pyogenic, resource limited settings, low-middle income countries


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