Klebsiella Pneumonia Liver Abscess: PO vs IV Antibiotics

In the past few years, there has been an increasing in the incidence of hypeviscous Klebsiella pneumoniae. This is typically caused by phenotypes associated with K1 and K2 capsule serotypes and is seen in southeast Asia and the classical pathology is that of a liver abscess (why this is I do not know). Recently, a CID article came out that compared IV therapy vs PO therapy in the hyperviscous K. pneumo liver abscess. While this shouldn’t be surprising to anyone in ID, it is nice to have some data to hang our hats on.

This was a multicenter, open-label, parallel group, RCT of early PO antibiotic vs IV antibiotics for K. pneumoniae liver abscess. Patients were assigned to either early PO or continued IV antibiotics in a 1:1 ratio. Primary endpoint was clinical cure at 12 weeks post-randomization, defined as CRP <20 mg/L + temperature <38 C and reduced maximal diameter of abscess at most recent imaging. Patients were drained at the discretion of the attending physician. A total of 152 patients were randomized (74 to PO antibiotics and 78 to IV antibiotics). Overall, there was no difference between PO and IV antibiotics (given for 4 weeks) between IV and PO antibiotics between the ITT analysis and the per protocol analysis:

This held true at 4 weeks and at 12 weeks:

This shouldn’t be surprising. The investigators used either PO ciprofloxacin (which gets nearly 100% bioavailability) and 1^st or 3^rd gen cephalosporin, except for those who were allergic to cephalosporins, in which case TMP-SMX was used. At the end of the day, drainage is what matters the most. Antibiotics tend to clean up the remaining “pus” that may be there following drainage. I believe the name of the game is source control, but it is always nice to have some data to guide my practice. While the numbers here weren’t great and it excluded critically ill patients, it is a fairly decent trial to guide the use of PO antibiotics for the hyperviscious K. pneumo liver abscess.

References:

Molton JS, Chan M, Kalimuddin S, Oon J, Young BE, Low JG, Salada BMA, Lee TH, Wijaya L, Fisher DA, Izharuddin E, Koh TH, Teo JWP, Krishnan PU, Tan BP, Woon WWL, Ding Y, Wei Y, Phillips R, Moorakonda R, Yuen KH, Cher BP, Yoong J, Lye DC, Archuleta S. Oral vs Intravenous Antibiotics for Patients With Klebsiella pneumoniae Liver Abscess: A Randomized, Controlled Noninferiority Study. Clin Infect Dis. 2020 Aug 14;71(4):952-959. doi: 10.1093/cid/ciz881. PMID: 31641767.