What is the management of splenic abscess?

From the Guidelines

Management of splenic abscess typically requires a combination of antibiotics and drainage procedures, with percutaneous drainage guided by CT or ultrasound being the preferred first-line intervention for accessible, unilocular abscesses, as recommended by the most recent guidelines 1. Initial treatment should include broad-spectrum antibiotics such as piperacillin-tazobactam 4.5g IV every 6 hours, or a combination of ceftriaxone 2g IV daily plus metronidazole 500mg IV every 8 hours, to cover both aerobic and anaerobic organisms. These should be adjusted based on culture results when available. Some key points to consider in the management of splenic abscess include:

• The use of antibiotics, with the choice of antibiotic depending on the suspected or confirmed causative organism, and the severity of the infection 1.
• The role of percutaneous drainage, which is preferred for accessible, unilocular abscesses, and can be performed under CT or ultrasound guidance 1.
• The potential need for surgical intervention, which may be necessary for multiple, multiloculated, or inaccessible abscesses, or in cases where percutaneous drainage is not possible or has failed 1.
• The importance of addressing the underlying cause of the abscess, such as endocarditis, hematological disorders, or immunosuppression, to prevent recurrence 1.
• The need for close monitoring for sepsis, as splenic abscesses carry a mortality rate of 10-20% if inadequately treated 1. Percutaneous drainage is the preferred first-line intervention for accessible, unilocular abscesses, and should be attempted where possible and safe, with splenectomy being reserved for cases where percutaneous drainage is not possible or has failed 1.

From the Research

Management of Splenic Abscess

The management of splenic abscess can be approached through various methods, including medical therapy, percutaneous drainage, and surgical intervention.

• Medical therapy alone may be considered for small splenic abscesses (less than 4 cm in diameter) 2.
• Percutaneous drainage under ultrasound or computed tomography guidance is recommended for larger abscesses (greater than 4 cm in diameter) 3, 2.
• Surgical intervention, such as splenectomy, may be reserved for cases where medical treatment has failed or is not feasible 3, 2.
• In cases of splenic abscess complicated by pleural empyema, management may include broad-spectrum antibiotics, tube thoracostomy, and percutaneous drainage of the splenic abscess 4, 5.

Treatment Approaches

Different treatment approaches have been reported in various studies:

• US-guided percutaneous aspiration of splenic abscesses is a safe and effective procedure that can be used as a bridge to surgery in critically ill patients or those with multiple comorbidities 3.
• Percutaneous aspiration may allow complete non-operative healing of splenic abscesses or temporize patients at risk for surgery 3.
• Simplified percutaneous drainage followed by open surgery abscess drainage can be a feasible approach in rural settings where resources are limited 5.
• Spleen preservation surgery along with antibiotics is preferable to retain immunologic functions 5.

Considerations

When managing splenic abscess, several factors should be considered:

• The size and location of the abscess, as well as the patient's overall condition, can influence the choice of treatment 2, 5.
• The presence of complications, such as pleural empyema, may require additional interventions, such as tube thoracostomy 4, 5.
• The goal of treatment should be to preserve the spleen and its immunologic functions whenever possible 5.