Cardiovasc Intervent Radiol (2015) 38:922–928
DOI 10.1007/s00270-014-1020-0
CLINICAL INVESTIGATION
Is Antibiotic Prophylaxis for Percutaneous Radiofrequency
Ablation (RFA) of Primary Liver Tumors Necessary? Results
From a Single-Center Experience
Shivank S. Bhatia • Seth Spector • Ana Echenique • Tatiana Froud
Rekha Suthar • Ivy Lawson • Ravi Dalal • Vy Dinh • Jose Yrizarry
Govindarajan Narayanan
Received: 25 April 2014 / Accepted: 28 September 2014 / Published online: 13 November 2014
Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) (outside the
US) 2014
Abstract
Purpose The purpose of this study was to evaluate need
for antibiotic prophylaxis for radiofrequency ablation
(RFA) of liver tumors in patients with no significant co-
existing risk factors for infection.
Materials and Methods From January 2004 to September
2013, 83 patients underwent 123 percutaneous RFA pro-
cedures for total of 152 hepatocellular carcinoma (HCC)
lesions. None of the patients had pre-existing biliary enteric
anastomosis (BEA) or any biliary tract abnormality pre-
disposing to ascending biliary infection or uncontrolled
diabetes mellitus. No pre- or post-procedure antibiotic
prophylaxis was provided for 121 procedures. Data for
potential risk factors were reviewed retrospectively and
analyzed for the frequency of infectious complications,
including abscess formation.
Results One patient (1/121 (0.8 %) RFA sessions)
developed a large segment 5 liver abscess/infected biloma
S. S. Bhatia (&)
A. Echenique
T. Froud
R. Suthar

I. Lawson
R. Dalal
J. Yrizarry
G. Narayanan
Vascular/Interventional Radiology, Department of Radiology,
Miller School of Medicine, University of Miami,
1475 NW 12 Avenue, Miami, FL 33136, USA
e-mail: sbhatia1@med.miami.edu
A. Echenique
e-mail: aechenique@med.miami.edu
T. Froud
e-mail: tfroud@med.miami.edu
R. Suthar
e-mail: rsuthar@med.miami.edu
I. Lawson
e-mail: i.lawson1@med.miami.edu
R. Dalal
e-mail: rdalal@med.miami.edu
123
INTERVENTIONAL ONCOLOGY
•
•
communicating with the gallbladder 7 weeks after the
procedure, successfully treated over 10 weeks with IV and
PO antibiotic therapy and percutaneous catheter drainage.
This patient did not receive any antibiotics prior to RFA.
During the procedure, there was inadvertent placement of
RFA probe tines into the gallbladder. No other infectious
complications were documented.
Conclusion These data suggest that the routine use of
prophylactic antibiotics for liver RFA is not necessary in
majority of the patients undergoing liver ablation for HCC
and could be limited to patients with high-risk factors such
as the presence of BEA or other biliary abnormalities,
uncontrolled diabetes mellitus, and large centrally located
tumors in close proximity to central bile ducts. Larger
randomized studies are needed to confirm this hypothesis.
Keywords Antibiotics
Radiofrequency ablation

Infections
Liver tumors
J. Yrizarry
e-mail: jyrizarr@med.miami.edu
G. Narayanan
e-mail: gnarayanan@med.miami.edu
S. Spector
Department of Surgery, VA Hospital (Veterans Affairs Medical
Center), University of Miami, 1201 NW 16th St., Miami,
FL 33125, USA
e-mail: sspector@med.miami.edu
V. Dinh
Department of Medicine, VA Hospital (Veterans Affairs Medical
Center), 1201 NW 16th St., Miami, FL 33125, USA
e-mail: vdinh@med.miami.edu
S. S. Bhatia et al.: Antibiotic Prophylaxis for Percutaneous RFA
Introduction
Any invasive procedure carries the risk of infection. The
use of prophylactic antibiotics for interventional radiology
(IR) procedures is usually based on personal or anecdotal
evidence or based on surgical literature. Lack of random-
ized controlled trials has led to routine use of antibiotic
prophylaxis as perceived standard of care without enough
evidence for most of the minimally invasive procedures [1–
4]. Percutaneous tumor ablation is one of many procedures
where prophylactic use of antibiotics is perceived standard
of care. There are a number of different ablation modali-
ties: radiofrequency ablation (RFA), microwave ablation,
cryoablation, and alcohol ablation, all of which offer an
excellent therapeutic alternative for liver and renal tumors
less than 3 cm, with a curative intent or as a salvage
therapy [1].
The society of interventional radiology (SIR) published
clinical practice guidelines (CPG) in 2010 (endorsed by
Cardiovascular Interventional Radiological Society of
Europe and Canadian Interventional Radiology Associa-
tion) for adult antibiotic prophylaxis during vascular and
IR procedures. This review stressed the need for current,
formal recommendations in the IR literature concerning the
appropriate use of prophylactic antibiotics for IR proce-
dures, acknowledging the increasing incidence of antibiotic
resistance and complications from nosocomial infection
[2].
IR procedures can be broadly classified on basis of the
National Academy of Sciences/National Research Council
guidelines dividing the surgical procedures into four cate-
gories—clean, clean-contaminated, contaminated, and
dirty (Table 1)—each of which is associated with a dif-
ferent risk of infection [2, 3, 5]. According to SIR CPG
guidelines, liver tumor ablation is considered to be a clean
procedure or a clean-contaminated procedure in the pre-
sence of a biliary enteric anastomosis. The same guidelines
Table 1 Surgical procedures’ categories according to National Academy of Sciences/National Research Council guidelines [2, 3, 5]
Categories Criteria
Clean 1. No GI, GU or respiratory tract entry
2. No evident inflammation
3. No break in aseptic technique
Clean-contaminated 1. GI, GU or biliary tract entry
2. No evident inflammation
3. No break in aseptic technique
Contaminated 1. Inflamed or colonized GI or GU tract entry
2. No frank pus
3. Major break in aseptic technique
Dirty 1. An infected purulent site entry e.g. abscess, a clinically
infected biliary or GU site, or perforated viscus
923
mention that there is currently no consensus on routine
antibiotic prophylaxis for percutaneous tumor ablation
procedures, and hence, there is no first-choice antibiotic
agent. Common antibiotic choices are as follows: (i) 1.5 g
ampicillin/sulbactam IV (liver); (ii) 1 g ceftriaxone IV
(renal); (iii) 1 g cefazolin IV (bone); and (iv) if penicillin-
allergic, can substitute vancomycin or clindamycin for
Gram-positive coverage; aminoglycoside for gram-nega-
tive coverage [2]. To date, due to lack of definitive scien-
tific evidence, many practitioners continue to use antibiotic
prophylaxis for ablation procedures; the antibiotic pro-
phylaxis regimen for RFA of liver in patients with no risk
factors as reported by various groups is summarized in
Table 2.
Given the cost of antibiotic therapy, antimicrobial
resistance, associated risks of superinfection, and lack of
scientific evidence for use of antibiotics in certain IR
procedures, it is more imperative than ever to address the
need for prophylaxis, especially in procedures where there
is no consensus recommendation and where they are
classified as ‘‘clean’’ procedures.
At our institution, the use of prophylactic antibiotics is
not performed prior to or following a RFA procedure. In an
attempt to address the controversial use of antibiotic pro-
phylaxis for RFA procedures, a total of 83 patients record
that underwent 123 percutaneous RFA procedures were
retrospectively reviewed to evaluate for post-procedure
abscess formation and/or infectious complications after
percutaneous RFA for hepatocellular carcinoma (HCC).
Materials and Methods
Over a 10-year period (from January 2004 to September
2013), 83 patients underwent 123 RFA procedures for
primary liver tumors at the institution. All the patients in
the study were males with mean age 65 ± 6 years (range:
Examples
Diagnostic angiography
Nephrostomy tube placement in a
patient with sterile urine
Transrectal biopsy
Percutaneous abscess drainage
123
924 S. S. Bhatia et al.: Antibiotic Prophylaxis for Percutaneous RFA

Table 2 Summary of antibiotic prophylaxis regimen for radiofrequency ablation of liver in patients with no risk factors as reported by various
groups
Author/year Recommended antibiotic regimen

Shibata et al. 2003 [7] 1 g cefazolin or cefmetazole 1 day before ablation therapy and 1 g every 12 h until discharge
De Baere et al. 2003 [23] Amoxicillin plus Clavulanic acid 2 g IV pre-procedure and 2 g/day PO for 2 days post-procedure
Mulier et al. [24] Amoxicillin plus Clavulanic acid, 1 pre-procedure dose
Dupuy et al. [25] Cefazolin 1 g
Beddy et al. [26] Ampicillin/beta lactamase inhibitor 1.5 g IV pre-procedure
Hoffman et al. [21] Ciprofloxacin 500 mg/d PO for 5 days post-procedure
Venkatasan et al. [2] 1.5 g ampicillin/sulbactam IV for liver

55–83 years). All had a diagnosis of HCC which had been
established by either surgical biopsy or by computed
tomography (CT) or magnetic resonance imaging (MRI)
criteria. IRB approval was obtained for retrospective
evaluation of the patients with HCC who underwent per-
cutaneous ablative therapy to evaluate the safety of liver
ablation without antibiotic prophylaxis with an analysis of
the effect of different variables including size of the tumor,
number of tumors treated, co-morbidities, e.g. diabetes
mellitus, Child-Pugh Score, and other risk factors for
infection (BEA or biliary tract abnormality/stent).
All the patients met the following inclusion criteria at
the time of RFA: (1) Single tumor less than 5.0 cm. or a
maximum of 3 tumors with none of tumors measuring
[3 cm in size. (2) No evidence of portal vein thrombosis
at imaging. (3) Child-Pugh classification A or B.
Tumors less than 3 cm in greatest dimension were
treated with a single ablation zone; larger lesions were
treated with multiple overlapping ablation zones to achieve
an adequate margin. The ablation zones varied from 3 to
7 cm. All the procedures were performed using RITA
(Angiodynamics, Mountain view, California) RFA probes.
The procedures were done under CT guidance by one of
the three experienced, board certified interventional radi-
ologists with adherence to standard sterile technique
practices, including the use of sterile drapes, gloves, and
gowns.
The patients were kept for overnight observation for
any evidence of acute complications. Patients were eval-
uated with physical examination and serum laboratory
tests in the outpatient clinic within 4 weeks after RFA
treatment and were then followed up at 3-month intervals
with abdominal CT or MRI scans, serum liver function
tests, and serum tumor markers as appropriate. Abdominal
CT or MRI scans were used to detect the evidence of
recurrent tumor in ablated lesions, to monitor the devel-
opment of new hepatic or extrahepatic metastatic disease,
and to detect any late sequel or complications related to
RFA treatment.
Evaluation of Risk Factors
We defined potential risk factors for liver abscess forma-
tion after RFA based on literature review. These include a
history of pre-existing BEA or any biliary tract abnormality
predisposing to ascending biliary infection, diabetes mel-
litus, Child-Pugh class B cirrhosis, tumor with retention of
iodized oil, history of prior chemoembolization, and lack of
antibiotic prophylaxis [6–9]. The frequency of post-abla-
tion infection was determined and quantified based on the
123 ablation procedures performed. This group of patients
was further analyzed and divided based on the patients’
history of risk factors mentioned above.
Results
Eighty three patients underwent 123 RFA sessions, and a
total of 152 tumors were ablated. Out of 83 patients, 20
(24 %) had diabetes mellitus and 41 (49.3 %) had cirrhosis
according to imaging. At the time of procedure, 68
(81.9 %) patients were Child-Pugh class A and 15 (18.1 %)
patients were class B. Number of tumors ranged from 1 to 3
per patient with average size 2.2 ± 0.8 cm (range:
1.0–4.7 cm; n = 152). Prior chemoembolization was
reported in 14 patients (16.8 %). None of the patients had
history of BEA. Antibiotic prophylaxis was given before
the procedure in 2 out of 123 RFA sessions (1.6 %). One
patient was on antibiotics due to co-existing septic arthritis
and another patient received antibiotic prophylaxis as per
the interventional radiologist’s discretion. These patients
were excluded from the study data analysis.
One patient developed a collection after the procedure
(1/121 (0.8 %) RFA sessions). This patient did not receive
any antibiotics prior to RFA and had a history of diabetes
mellitus, alcoholic cirrhosis, hepatitis C, gout, and
depression. The patient had a Child-Pugh score B and stage
II HCC at the time of the procedure. RFA was performed
for a recurrent segment 6 lesion, 2.5 cm in size; and a

123
S. S. Bhatia et al.: Antibiotic Prophylaxis for Percutaneous RFA
Fig. 1 The patient is a 54-year-old male with a medical history of
alcoholic cirrhosis, hepatitis C, diabetes mellitus, gout, and depres-
sion, who was diagnosed with stage II hepatocellular carcinoma. RFA
was performed for a recurrent segment 6 lesion, 2.5 cm in size; and a
segment 5 lesion, 3.0 cm in size located in close proximity to
gallbladder fossa. Inadvertent placement of ablation probe tines
within the gall bladder was noted in retrospect (a). The patient
segment 5 lesion, 3.0 cm in size located in close proximity
to gallbladder fossa. During the procedure, there was
inadvertent placement of tines in gallbladder. The patient
presented 7 weeks later with a large segment 5 liver col-
lection communicating with the gallbladder. The cultures
from the aspirate were positive for group C streptococci.
The infected collection, favored to be an abscess, was
treated successfully with percutaneous catheter drainage
for 10 weeks and intravenous antibiotics Ceftriaxone
(active substance: Ceftriaxone Sodium) and Flagyl (active
substance: metronidazole) (Fig. 1).
The only infection which developed after RFA was due
to gallbladder injury during the RFA procedure. The
absence of infectious complications in all but this patient
supports our hypothesis that prophylactic antibiotics are
not necessary.
Discussion
Antibiotic prophylaxis for various IR procedures has been
defined by SIR in CPG published in 2010; however,
925
developed a collection communicating with gallbladder approxi-
mately 7 weeks after the RF ablation (b) which was demonstrated on
CT during interval follow-up. The patient was treated with intrave-
nous antibiotics and a percutaneous catheter drainage catheter (c). A
follow-up CT 3 weeks after treatment with a percutaneous drainage
catheter shows complete resolution of the collection (d); interval
development of ascites is noted
prophylaxis in certain organ systems and during certain
procedures remains controversial [2]. The rationale of
antibiotic usage in IR procedures has been based mostly on
the surgical literature. However, the risk of infectious
complications after IR procedures is not necessarily
equivalent to surgical procedures, where the goal of pro-
phylaxis is prevention of wound infection [3, 10].
The clinical and financial impacts of overuse of antibi-
otics are far from inconsequential. It leads to antibiotic
resistance which potentially adds considerable and avoid-
able costs to the already overburdened healthcare system.
The estimates of the total cost of antibiotic resistance to the
U.S. economy vary but have ranged as high as $20 billion
in excess direct health care costs, with additional costs to
society in terms of productivity as high as $35 billion a
year (2008 dollars) [11]. Rates of antibiotic associated
diarrhea (AAD) range from 1 to 44 % depending on pop-
ulation and type of antibiotic used [12, 13]. Clostridium
difficile infection (CDI) is the primary cause of AAD and is
responsible for 10–25 % of all cases of AAD, with
symptoms of CDI ranging from mild to moderate diarrhea
to pseudomembranous colitis or toxic megacolon [14, 15].
123
926
Table 3 Previously identified risk factors which predispose to infection/abscess formation after RFA
Author/year No. of patients, Liver abscess
procedures, and
treated lesions
Choi et al. 2005 [20] 603/751/831 13/751 (1.7 %)
Shibata et al. 2003 [7] 358/683/455 10/683 (1.5 %)
Livraghi et al. 2003 [6] 2320/NS/3554 6/2320 (0.3 %)
De Baere et al. 2003 [23] 312/350/582 7/350 (2 %)
Mulier et al. 2002 [24] 3670/NS/NS 34/3670 (1 %)
According to Centers for Disease Control and Preven-
tion (CDC), the estimated 250,000 cases of CDI occur
annually in the US, with a corresponding burden on the
healthcare system in excess of at least $1 billion [16]. CDC
Vital Signs monthly report from March 2014 suggests
reducing the use of high-risk antibiotics by 30 % can lower
the deadly diarrhea infection by 26 % [17].
RFA is a relatively safe technique with low morbidity
and mortality [6]. The commonly reported major compli-
cations include intraperitoneal hemorrhage, hemobilia,
gastrointestinal perforation, pleural effusion, and liver
abscess [4, 18, 19]. Less than 2 % of liver ablations result
in an infectious complication [6, 7, 20]. Several risk factors
have been identified which predispose to infection/abscess
formation after RFA (Table 3). Commonly reported risk
factors include biliary abnormalities like a surgical bilio-
enteric anastomosis (BEA), the presence of biliary catheter
or stent in situ, and uncontrolled diabetes mellitus [6–9].
The presence of biliary tract contamination has been the
most commonly reported risk factor in development of
liver abscess formation after RFA procedure in liver [7–9,
19–21]. BEA, the presence of biliary stent or sphincterot-
omy can lead to retrograde enteric bacterial contamination
of the biliary tract and pose a high risk for abscess for-
mation [2]. Hoffmann et al. have recommended the use of
pre-procedure and post-procedure oral antibiotic prophy-
laxis in this particular group. Their group reported one
abscess formation out of 184 patients undergoing RFA, in a
patient with BEA even with the use of pre- and post-pro-
cedure antibiotic prophylaxis [21]. In the patients with
BEA, the timeline for development of liver abscess is
123
S. S. Bhatia et al.: Antibiotic Prophylaxis for Percutaneous RFA
Reported risk factors Prophylactic antibiotic regimen
Pre-existing biliary abnormality prone None
to ascending biliary infection, tumor
with retention of iodized oil, and
treatment with an internally cooled
electrode system
Bilioenteric anastomosis 1 g cefazolin or cefmetazole 1 day
before ablation therapy and 1 g
every 12 h until discharge
2/6 patients had DM, 2/6 patients with 3/6 received prophylactic antibiotics,
bilioenteric anastomosis, 3/6 no regimen unknown
prophylactic antibiotics, no
comments on if any of these were
statistically significant
Bilioenteric anastomosis (all patients Received 5 day course of amoxillin
with bilioenteric anastomosis and clavulanate prior to procedure
(n = 3) developed abscess)
Biliary abnormality in 8 patients, no Amoxicillin plus clavulanic acid,
risk factors summarized duration of 48 h
usually 2–10 weeks after the procedure [8]. This group of
patients, apart from receiving pre- and post-procedure
antibiotic prophylaxis, should also be warned and watched
closely after the procedure for any signs/symptoms of
infection [21].
The mechanism of abscess formation is not well
understood; however, it is believed to result from con-
tamination of necrotic tissue [1, 6, 20]. Thermal injury
from RFA can connect biliary ducts with the ablation zone,
creating a route for contamination from enteric bacteria in
patients with underlying BEA [1, 6, 20]. The most com-
monly encountered organisms include Staphylococcus
aureus, Staphylococcus epidermidis, and Streptococcus
species with or without E. coli. In patients with BEA,
additional species to be considered include Proteus, Kleb-
siella, and Enterococcus [2]. The timeframe of developing
abscess after the RFA procedure is reported within 30 days
after the procedure. As described by Mendiratta-Lala et al.,
transient post-ablation fevers are usually due to a post-
ablation syndrome rather than bacteremia. However, a
persistent fever greater than 2 weeks suggests abscess
formation. Conventional management of a liver abscess
includes hospitalization with IV antibiotics and percuta-
neous drainage of the abscess [9].
Multiple studies have been reported evaluating compli-
cations after RFA of liver tumors with some studies
focusing on rate of infection and evaluation of risk factors.
In the largest study reported to date, Livraghi evaluated
2,320 patients for complications of RFA of liver in a
multicenter study. The study showed a very low rate,
(0.3 %), of intrahepatic abscess formation [6]. For many of
S. S. Bhatia et al.: Antibiotic Prophylaxis for Percutaneous RFA
the centers involved in the study, however, the protocol for
antibiotic administration was evolving; thus the exact
number of patients receiving antibiotics could not be
assessed. Out of the six patients with abscesses, three
patients received prophylactic antibiotics, including two
patients with BEA and one with diabetes mellitus. Of the
three patients who did not receive prophylactic antibiotics,
two had diabetes mellitus. In our practice as a routine, if
the blood sugar levels are abnormally high on day of the
procedure, we admit the patient for aggressive sugar con-
trol and perform ablation next day or reschedule for a later
date.
Choi et al. demonstrated a 1.7 % abscess formation rate
in his study of 751 patients. All patients were treated with
IV or oral antibiotics after RFA procedure; however, no
pre-procedure prophylaxis was given. The authors con-
cluded that tumors with retention of iodized oil, diabetes
mellitus, and treatment with internally cooled electrode
system also have an association with infection after RFA
[20].
Curley et al. in 2004 evaluated early and late compli-
cations of RFA procedures in 608 patients with primary
and secondary malignancies. No prophylactic antibiotic
regimen was discussed in this study. This group reported
10 cases of abscess formation within 30 days of the pro-
cedure, all treated with intravenous antibiotics. All the
infectious complications within first 30 days occurred in
patients undergoing open RFA. Only one patient under-
going percutaneous RFA developed liver abscess 30 days
after the procedure [22].
Our results suggest that early or late infectious com-
plications in patients undergoing RFA despite no pre-pro-
cedure or post-procedure antibiotic prophylaxis are very
rare. We encountered one collection favored to be an
abscess; however, an infected biloma could not be exclu-
ded. This was due to technical issue with placement of
probe into the gallbladder lumen. Since antibiotics do not
seem to prevent infection in these groups of patients, and
can make diagnosis of infecting species more difficult, a
more prudent approach may be to maintain close surveil-
lance of patients in the early post-operative period and
intervene promptly at any signs and symptoms of infection.
There were no infection-related mortalities in the publi-
cations cited or in our series.
Our study has several limitations including retrospective
nature, lack of control arm, and a relatively small sample
size. All tumors included in our study were hepatomas, and
our data are limited to thermal ablation. All the percuta-
neous RFAs performed in our study had an ablation zone of
less than 7 cm.
To conclude, we present a review of 123 percutaneous
liver RFA procedures for primary hepatomas with one
incident of abscess/infected biloma formation, due to
927
inadvertent placement of probe tines into the gallbladder
lumen. The routine use of prophylactic antibiotics for liver
RFA may be necessary for patients with high-risk factors
such as the presence of BEA or other biliary abnormalities,
uncontrolled diabetes mellitus, or large centrally located
tumors in close proximity to bile ducts. However, the
routine use of prophylactic pre/post-procedure antibiotics
for RFA of liver tumors without underlying risk factors is
not warranted. Larger randomized studies are needed to
confirm this hypothesis.
Conflict of interest Shivank S. Bhatia: Speaker for Angiodynamics
and Govindarajan Narayanan: Consultant and Speaker for Angiody-
namics. Seth Spector, Ana Echenique, Tatiana Froud, Rekha Suthar,
Ivy Lawson, Ravi Dalal, Vy Dinh, and Jose Yrizarry declare that they
have no conflict of interest.
Statement of Informed Consent For this type of study, formal
consent is not required. This article does not contain any studies with
animals by any of the authors.
References
1. McWilliams JP, Yamamoto S, Raman SS et al (2010) Percuta-
neous ablation of hepatocellular carcinoma: current status. J Vasc
Interv Radiol 21(8):S204–S213
2. Venkatesan AM, Kundu S, Sacks D et al (2010) Practice guide-
lines for adult antibiotic prophylaxis during vascular and inter-
ventional radiology procedures. Written by the Standards of
Practice Committee for the Society of Interventional Radiology
and Endorsed by the Cardiovascular Interventional Radiological
Society of Europe and Canadian Interventional Radiology
Association [corrected]. J Vasc Interv Radiol 21(11):1611–1630
quiz 1631
3. McDermott VG, Schuster MG, Smith TP (1997) Antibiotic pro-
phylaxis in vascular and interventional radiology. AJR Am J
Roentgenol 169(1):31–38
4. Gervais DA, Goldberg SN, Brown DB et al (2009) Society of
interventional radiology position statement on percutaneous
radiofrequency ablation for the treatment of liver tumors. J Vasc
Interv Radiol 20(1):3–8
5. Ad Hoc Committee of the Committee on Trauma, Division of
Medical Sciences, National Academy of Sciences, National
Research Council Postoperative wound infections (1964) The
influence of ultraviolet irradiation of the operating room and
various other factors. Ann Surg 160:1–192
6. Livraghi T, Solbiati L, Meloni MF et al (2003) Treatment of focal
liver tumors with percutaneous radio-frequency ablation: com-
plications encountered in a multicenter study. Radiology 226(2):
441–451
7. Shibata T, Yamamoto Y, Yamamoto N et al (2003) Cholangitis
and liver abscess after percutaneous ablation therapy for liver
tumors: incidence and risk factors. J Vasc Interv Radiol 14(12):
1535–1542
8. Elias D, Di Pietroantonio D, Gachot B et al (2006) Liver abscess
after radiofrequency ablation of tumors in patients with a biliary
tract procedure. Gastroenterol Clin Biol 30(6–7):823–827
9. Mendiratta-Lala M, Brook OR, Midkiff BD et al (2010) Quality
initiatives: strategies for anticipating and reducing complications
and treatment failures in hepatic radiofrequency ablation. Ra-
diographics 30(4):1107–1122
123
928
10. Wenzel PR (1992) Preoperative antibiotic prophylaxis. N Engl J
Med 326:337–339
11. http://www.tufts.edu/med/apua/consumers/personal_home_5_
1451036133.pdf (accessed 8-5-2013) and extrapolated from
Roberts RR, Hota B, Ahmad I, et al. (2009 Oct 15) Hospital
and societal costs of antimicrobial-resistant infections in a
Chicago teaching hospital: implications for antibiotic stew-
ardship. Clin Infect Dis 49(8): 1175–84
12. Bergogne-Berezin E (2000) Treatment and prevention of antibi-
otic associated diarrhea. Int J Antimicrob Agents 16(4):521–526
13. Graul T, Cain AM, Karpa KD (2009) Lactobacillus and bifido-
bacteria combinations: a strategy to reduce hospital-acquired
Clostridium difficile diarrhea incidence and mortality. Med
Hypotheses 73(2):194–198
14. Bartlett JG, Gerding DN (2008) Clinical recognition and diag-
nosis of Clostridium difficile infection. Clin Infect Dis
46(1):S12–S18
15. Janka J, O’Grady NP (2009) Clostridium difficile infection:
current perspectives. Curr Opin Crit Care 15(2):149–153
16. Centers for Disease Control and Prevention. Antibiotic resistance
threats in the United States, 2013. Last reviewed: September
2013, last updated: March 2014 (available at http://www.cdc.gov/
drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf,
accessed March/11, 2014)
17. National Center for Emerging and Zoonotic Infectious Diseases,
Division of Healthcare Quality Promotion. Making Health Care
Safer Antibiotic Rx in Hospitals: Proceed with Caution. Last
reviewed and updated: March 2014 (available at http://www.cdc.
gov/vitalsigns/pdf/2014-03-vitalsigns.pdf, accessed March/11,
2014)
18. Akahane M, Koga H, Kato N et al (2005) Complications of
percutaneous radiofrequency ablation for hepato-cellular carci-
noma: imaging spectrum and management. Radiographics
25(1):S57–S68
123
S. S. Bhatia et al.: Antibiotic Prophylaxis for Percutaneous RFA
19. Rhim H, Yoon KH, Lee JM et al (2003) Major complications
after radio-frequency thermal ablation of hepatic tumors: spec-
trum of imaging findings. Radiographics 23(1):123–134 discus-
sion 134–6
20. Choi D, Lim HK, Kim MJ et al (2005) Liver abscess after percuta-
neous radiofrequency ablation for hepatocellular carcinomas: fre-
quency and risk factors. AJR Am J Roentgenol 184(6):1860–1867
21. Hoffmann R, Rempp H, Schmidt D et al (2012) Prolonged anti-
biotic prophylaxis in patients with bilioenteric anastomosis
undergoing percutaneous radiofrequency ablation. J Vasc Interv
Radiol 23(4):545–551
22. Curley SA, Marra P, Beaty K et al (2004) Early and late com-
plications after radiofrequency ablation of malignant liver tumors
in 608 patients. Ann Surg 239(4):450–458
23. de Baere T, Risse O, Kuoch V et al (2003) Adverse events during
radiofrequency treatment of 582 hepatic tumors. AJR Am J
Roentgenol 181(3):695–700
24. Mulier S, Mulier P, Ni Y et al (2002) Complications of radiofre-
quency coagulation of liver tumours. Br J Surg 89(10):1206–1222
25. Dupuy DE, Goldberg SN (2001) Image-guided radiofrequency
tumor ablation: challenges and opportunities–part II. J Vasc In-
terv Radiol 12(10):1135–1148
26. Beddy P, Ryan JM (2006) Antibiotic prophylaxis in interven-
tional radiology–anything new? Tech Vasc Interv Radiol 9(2):
69–76