A 62-year-old woman with a history of type 2 diabetes mellitus is evaluated on hospital da… — USMLE Step 2 CK

A $62$ -year-old woman with a history of type 2 diabetes mellitus is evaluated on hospital day $6$ for management of a pyogenic liver abscess. She originally presented with high fever, malaise, and severe right upper quadrant abdominal pain. Imaging on admission revealed a $5\text{-cm}$ thick-walled fluid collection in the right hepatic lobe. She was started on empiric intravenous piperacillin-tazobactam, and a percutaneous drain was placed by interventional radiology.

The patient's clinical status has significantly improved. She has been afebrile for $72$ hours, and her leukocyte count has decreased from $18,000/\mu\text{L}$ to $9,500/\mu\text{L}$ . The percutaneous drain output has been less than $15\text{ mL}$ over the last $24$ hours. Abscess fluid cultures drawn during placement show pure growth of *Klebsiella pneumoniae*. Susceptibility testing demonstrates the organism is susceptible to ceftriaxone, ciprofloxacin, and piperacillin-tazobactam, but resistant to ampicillin.

Which of the following is the most appropriate next step in management?

Remove the percutaneous drain and transition to oral ciprofloxacinAnswer
B
Remove the percutaneous drain and continue intravenous piperacillin-tazobactam
C
Remove the percutaneous drain and transition to intravenous ceftriaxone
D
Leave the percutaneous drain in place and transition to oral ciprofloxacin
E
Remove the percutaneous drain and discontinue all antimicrobial therapy

Answer

Remove the percutaneous drain and transition to oral ciprofloxacin.

The correct answer involves removing the percutaneous drain and transitioning the patient to oral ciprofloxacin. The patient has a pyogenic liver abscess and has shown significant clinical improvement, marked by the resolution of fever, a normalized leukocyte count, and minimal drain output (less than

20\text{ mL/day}

). These parameters indicate that the percutaneous drain has served its purpose and can be safely removed, preventing secondary infections and patient discomfort. Furthermore, pyogenic liver abscesses require a prolonged total course of antibiotics, typically

4

6

weeks, to ensure complete eradication and prevent relapse. Because the culture demonstrates pure growth of *Klebsiella pneumoniae* that is susceptible to ciprofloxacin, and the patient is clinically stable, de-escalating to a highly bioavailable oral antibiotic is the optimal next step. This adheres to the core principles of antibiotic stewardship by narrowing the spectrum of coverage, transitioning to oral therapy, and facilitating prompt hospital discharge.

Step-by-Step Solution

Evaluate the patient's clinical response and percutaneous drain output.

The patient is clinically stable (afebrile, normalizing leukocyte count) with minimal drain output (less than

15\text{ mL/day}

Determines if the source control is adequate and if the drain can be safely removed to prevent nosocomial complications.

Analyze the abscess fluid culture and susceptibility results.

Cultures grew pure *Klebsiella pneumoniae* that is susceptible to oral ciprofloxacin.

Guides the de-escalation of empiric broad-spectrum antibiotics to targeted therapy.

Determine the appropriate duration and route of ongoing antibiotic therapy.

Transition to a highly bioavailable oral agent (ciprofloxacin) to complete a

4

6

week total course.

Ensures complete eradication of the pyogenic liver abscess while adhering to antibiotic stewardship and facilitating hospital discharge.

Key Concept

Pyogenic liver abscesses are managed with percutaneous drainage and a

4

6

week total course of antibiotics. Drains should be removed when output is

< 20\text{ mL/day}

, and clinically stable patients should be transitioned to targeted, highly bioavailable oral antibiotics to promote antibiotic stewardship.

Estimated Time:1m 30s

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