Large retrospective study analysing predictive factors of primary treatment failure, recurrence and death in pyogenic liver abscesses

Prognosis of liver abscess in the intensive care unit (POLAIR), a multicentre observational study

BACKGROUND

Liver abscess (LA) is a rare but potentially serious condition with a high mortality rate. Current epidemiological data of LA patients requiring intensive care unit (ICU) admission are limited.

METHODS

This multicentre retrospective study included adults admitted to 24 ICUs in France between January 2010 and December 2020. Risk factors for mortality were identified by multivariate analysis. A propensity score was used to adjust for confounders related to the presence of portal vein thrombosis.

RESULTS

335 patients were enrolled. The median age was 66 years [53-73] and 68% were male. Commons comorbidities included diabetes (29.9%) and cancer or haematological disease. Septic shock was the main reason for admission (58%). The median SAPS2 score at ICU admission was 42 [31-53] and the SOFA score was 6 [3-9]. The putative origin of LA was biliary (31%), while 40% were cryptogenic. Most patients (60%) had a solitary LA, involving the right lobe (38.8%), with a median diameter of 67 mm [47-91]. Associated portal vein thrombosis (PVT) was present in 13.4% of cases. Microbiological documentation was obtained in 82% of patients, showing gram-negative bacilli (59.7%), mainly Escherichia coli (19.6%) and Klebsiella spp. (19.1%), and gram-positive cocci (29.6%), mainly Streptococcus spp. (17.1%). Drainage was performed in 62% of cases, 40% within 48 h. The median duration of antibiotic therapy was 35 days [21-42]. During hospitalisation, 62% of patients required vasopressors and 29% required mechanical ventilation. In-ICU mortality was 11.6%. Multivariate analysis showed that organ dysfunction illustrated by SOFA score (HR 3.45 [1.95-6.09], p < 0.001) and PVT (HR 3.14 [1.54-6.39], p = 0.001) were significant risk factors for mortality. Drainage was not associated with improved short-term survival (HR 1.22 [0.65-2.72], p = 0.52). In the population matched for PVT confounders, a higher sofa score was the only factor associated with mortality (HR 3.11 [1.76-5.49] IC95%, p = 0.001).

CONCLUSIONS

This multicentre study illustrates the severity of LA in French intensive care units and identifies organ dysfunction (SOFA score) and portal vein thrombosis as major risk factors for mortality. Prospective studies are needed to improve management strategies, as the survival benefit of drainage is unclear.

Uncovering the unseen: Metagenomic next-generation sequencing improves liver abscess diagnostics

BACKGROUND

This study retrospectively analyzed the metagenomic next-generation sequencing (mNGS) results and clinical data from patients with liver abscess (LA) to investigate the clinical value of mNGS in the diagnosis of LA.

METHODS

This retrospective observational study included patients with LA who were admitted to Peking Union Medical College Hospital (PUMCH) between April 2022 and July 2024. We comprehensively analyzed the final clinical etiological diagnosis, traditional pathogen detection through conventional microbiological testing (CMT), and mNGS results in terms of pathogen type and specimen turnaround time.

RESULTS

Among 60 patients with LA, 19 types of pathogens were identified. Using clinical etiological diagnosis as the standard, mNGS identified all pathogens, whereas CMT identified only 42.11 % of pathogens. The true-positivity rate of mNGS (86.67 %) was significantly higher than that of CMT (58.33 %; P < 0.001). The average specimen turnaround time for mNGS (57.66 h) was shorter than that for CMT (86.54 hours, P < 0.001).

CONCLUSIONS

Compared with existing CMT, mNGS offers higher true-positive rates, broader pathogen coverage, and shorter specimen turnaround time. These advantages contribute to more accurate clinical diagnosis and treatment.

Successful cure of multiple large, inoperable liver abscesses by antibiotic therapy

PURPOSE

Pyogenic liver abscesses are challenging due to their diverse etiology and the risk of severe complications. In many cases, surgical interventions are initiated. However, these are only applicable in selected scenarios. We report the case of a 63-year-old woman with multiple large liver abscesses of up to 6.7 cm spread across both liver lobes, which could not be managed surgically.

METHODS & RESULTS

Streptococcus intermedius was isolated in blood culture and PCR positivity for this pathogen was obtained in liver puncture specimen. Following a two-weeks course of intravenous therapy with cefuroxime, metronidazole and fosfomycin, the patients received a consecutive, combined oral antibiotic treatment with clindamycin and cephalexin for four months. This resulted in complete resolution of the abscesses, with no evidence of relapse at follow-up.

CONCLUSION

This case illustrates the complex therapeutic challenges in the management of multiple, large hepatic abscesses, highlighting the potential of antibiotic therapy to cure even inoperable patients.

Management and prognostic prediction of pyogenic liver abscess in a Chinese tertiary hospital: Percutaneous needle aspiration vs catheter drainage

Pyogenic liver abscess (PLA) is a serious infectious disease with high mortality. The aim of our study was to compare the efficacy of percutaneous needle aspiration (PNA) and percutaneous catheter drainage (PCD) for PLA and to assess risk factors for unfavorable prognosis. This retrospective study was performed between 2017 to 2019 in a Chinese tertiary care hospital. We compared the therapeutic effectiveness of PNA versus PCD for PLA and analyzed the risk factors of treatment failure in PLA patients using multivariate logistic regression. A total of 445 patients with PLA were enrolled. The ultrasound-guided percutaneous treatment showed good therapeutic effects on PLA, with a total primary cure rate of 90.1%. PNA appeared to have advantages over PCD, with higher success rates, lower costs, and shorter hospital stays, as well as fewer puncture-induced pain, especially in patients with abscesses of 5-10 cm in diameter. The presence of positive blood culture (OR: 3.32, p = 0.002), liver cirrhosis (OR: 3.31, p = 0.023), and the length of fever resolution (OR: 1.043, p = 0.001) were independent predictors of primary treatment failure. PNA is more advantageous than PCD and is worth considering as a first-line treatment.

Bio inspired microfluidic-based analysis of Klebsiella pneumoniae virulence factors and antimicrobial resistance

The objective of this research was to examine the antibiotic resistance and microbiological traits of Klebsiella pneumoniae isolates that were responsible for liver abscesses in Qingdao, China. Between April and September 2022, isolates were taken from 120 patients at three tertiary hospitals. Rapid detection of capsule serotypes (K1, K2) and virulence genes (rmpA, aerobactin) was achieved by using microfluidic-based techniques. Testing for antimicrobial susceptibility was done with the VITEK 2 Compact system. The findings showed that there was a high frequency of extremely virulent K. pneumoniae strains, which are often linked to bacteremia and higher death rates. These strains belonged to the K1 and K2 serotypes and were primarily carrying the aerobactin and rmpA genes. The majority of isolates were antibiotic-sensitive, but the emergence of resistant strains emphasizes the necessity of continuing surveillance. The efficiency of microfluidic platforms for the quick and precise characterization of K. pneumoniae is demonstrated in this work, enabling prompt clinical interventions.

Clinical features and risk factors for pyogenic liver abscess caused by multidrug-resistant organisms: A retrospective study

The incidence rate of pyogenic liver abscess caused by multidrug-resistant bacteria has increased in recent years. This study aimed to identify the clinical characteristics and risk factors for pyogenic liver abscess caused by multidrug-resistant bacteria. We conducted a retrospective analysis of the clinical features, laboratory test results, and causes of pyogenic liver abscesses in 239 patients admitted to a tertiary hospital. Multivariable logistic regression was used to identify risk factors for multidrug resistance. Among patients with pyogenic liver abscesses, the rate of infection caused by multidrug-resistant organisms was observed to be 23.0% (55/239), with a polymicrobial infection rate of 14.6% (35/239). Additionally, 71 cases (29.7%) were associated with biliary tract disease. Patients with pyogenic liver abscesses caused by multidrug-resistant organisms had a significantly higher likelihood of polymicrobial infection and increased mortality (7/44 [15.9%] vs. 3/131 [2.3%]; p = .003). The Charlson Comorbidity Index (adjusted odds ratio [aOR]: 1.32, 95% confidence interval [CI]: 1.06-1.68), hospitalization (aOR: 10.34, 95% CI: 1.86-60.3) or an invasive procedure (aOR: 9.62; 95% CI: 1.66-71.7) within the past 6 months, and gas in the liver on imaging (aOR: 26.0; 95% CI: 3.29-261.3) were independent risk factors for pyogenic liver abscess caused by multidrug-resistant bacteria. A nomogram was constructed based on the risk factors identified. The nomogram showed high diagnostic accuracy (specificity, 0.878; sensitivity 0.940). Multidrug-resistant organisms causing pyogenic liver abscesses have specific characteristics. Early identification of patients at high risk of infection with multidrug-resistant organisms could help improve their management and enable personalized treatment.

Clinical management, pathogen spectrum and outcomes in patients with pyogenic liver abscess in a German tertiary-care hospital

Pyogenic liver abscesses (PLA) are life-threatening disorders and require immediate treatment, but structured evidence is sparse and treatment guidelines are not established. In a retrospective observational study of 221 adult PLA patients (mean age 63 years, 63% men) treated between 2013 and 2019 at the Leipzig University Medical Center, we characterized pathogen spectrum, clinical management and outcomes. Biliary malignancies (33%), cholelithiasis (23%) and ischemic biliary tract disease (16%) were most common causes of PLA. Comorbidities included malignancies (40%) and diabetes mellitus (35%). Abdominal ultrasound was the preferred initial imaging modality (58%). Enterobacterales (58%), enterococci (42%) and streptococci (18%) were identified as most frequent pathogens. 97% of patients were treated with antibiotics and 75% of patients underwent an invasive treatment procedure. The 30-day mortality was almost identical in patients with and without underlying malignancy (14.6% vs. 14.4%, p = 0.96), while the one-year outcome differed significantly (58.4% vs. 29.6%, p < 0.001). Positive blood cultures (OR 4.78, 95% CI 1.39 to 22.5, p = 0.023) and detection of Enterobacterales (OR 3.55, 95% CI 1.40 to 9.97, p = 0.010) were associated with increased 30-day-mortality. We conclude that ultrasound, extensive microbiologic diagnosis, adequate anti-infective therapy and early intervention are crucial for the management of PLA.

Demographics and prognosis of patients with pyogenic liver abscess due to Klebsiella pneumonia or other species

Background

Pyogenic liver abscess (PLA) is a potentially life-threatening intra-abdominal infection. We compared the clinical features, treatments, and prognoses of patients who had Klebsiella pneumonia pyogenic liver abscess (KPPLA) and non-Klebsiella pneumonia pyogenic liver abscess (non-KPPLA).

Methods

A retrospective analysis was used to compare the medical records of KPPLA and non-KPPLA patients with positive pus cultures at a single hospital in China from January 2017 to December 2019.

Results

We examined 279 patients with definitively established PLA, 207 (74.2 %) with KPPLA, and 72 with non-KPPLA. The non-KPPLA group had a higher Charlson comorbidity index, longer hospital stay, longer duration of fever, and greater hospital costs. Multivariate analysis showed that alcohol intake (OR: 2.44, P = 0.048), cancer (OR: 4.80, P = 0.001), ICU admission (OR: 10.61, P = 0.026), resolution of fever OR: 1.04, P = 0.020), and a positive blood culture (OR: 2.87, P = 0.029) were independent predictors of primary treatment failure. Percutaneous needle aspiration (PNA) and pigtail catheter drainage (PCD) provided satisfactory outcomes, but PNA led to shorter hospital stays and reduced costs, especially in KPPLA patients whose abscesses were smaller than 10 cm.

Conclusion

KPPLA and non-KPPLA patients had some differences in comorbidities and treatment strategies, and non-KPPLA patients had a significantly worse prognosis.

Bacteremia from streptococcus constellatus revealing a gastrointestinal stromal tumor

BACKGROUND

Pyogenic Liver Abscesses (PLA) are the most common type of visceral abscess. They generally develop in a context of biliary disease or hematogenous seeding, but a complete diagnostic work-up is always required in order not to miss other important causes, including above all malignancies of the gastro-intestinal tract.

CASE PRESENTATION

Herein, we report a particular case of a 80 years-old immunocompetent woman hospitalized for sepsis. At the end of the diagnostic process, Streptococcus constellatus (Sc) was identified as the cause of sepsis, multiple PLA were found together with a previous unknown ileal malignancy. We speculated about a possible correlation among these three entities (i.e. sepsis from Sc, PLA and tumors).

CONCLUSIONS

Detection of Sc in blood should raise red flags in clinicians as aggressive clinical presentation are possible.

Analysis of 15 cases from a monocentric cohort of 307 liver abscesses

BACKGROUND

Out of the context of haematological patients, Candida sp. is rarely retrieved from pyogenic liver abscesses (PLA).

OBJECTIVES

Our objective was to assess the risk factors for occurrence, and clinical, microbiological characteristics, management and outcome of Candida pyogenic liver abscesses (C-PLA).

PATIENTS/METHODS

We retrospectively analysed C-PLA cases and compared them to pyogenic liver abscesses exclusively due to bacteria (B-PLA) included in our monocentric database on liver abscesses. Unfavourable course was defined as the occurrence of a primary treatment failure (PTF), recurrence after an initial cure, or death within 3 months after diagnosis.

RESULTS

Between 2010 and 2018, 15 C-PLA and 292 B-PLA were included. All C-PLA had a biliary origin and were polymicrobial. All patients with C-PLA had at least one comorbidity at risk for Candida infection and 7 (53.3%) presented with sepsis requiring an admission in intensive care unit. Median duration of antifungal treatment was 42 days [24-55]. In multivariate analysis, compared with B-PLA, a medical history of malignancy (OR 4.16; 95%CI 1.15-18.72) or liver abscess (OR 7.39; 95%CI 2.10-26.62), and sepsis with severity criteria (OR 3.52; 95%CI 1.07-11.90) were independently associated with the occurrence of C-PLA. In multivariate analysis, C-PLA was associated with a higher risk of recurrence (HR 3.08; 95%CI 1.38-11.22).

CONCLUSION

Candida liver abscesses in non-neutropenic is a rare and severe disease. The high rate of recurrence should lead to discuss a more intensive treatment.

Evaluation of the contribution of shotgun metagenomics in the microbiological diagnosis of liver abscesses

BACKGROUND

Shotgun metagenomics (SMg) sequencing has gained a considerable interest, as it enables the detection of any microorganisms through a single analysis. Due to the limitations of standard microbiological approaches, the microbial documentation of liver abscesses (LA), which is crucial for their medical management, can be difficult. Here we aimed to compare the performance of SMg with standard approaches for the microbiological documentation of LA.

METHODS

In this retrospective study conducted at two centers, we compared the results of standard microbiology with metagenomics analysis of consecutive LA samples. For samples tested positive for Klebsiella pneumoniae, we compared the analysis of virulence and resistance genes using metagenomics data to whole-genome sequencing of corresponding isolates obtained in culture.

RESULTS

Out of the 62 samples included, standard approaches and SMg yielded documentation in 80.6% and 96.8%, respectively. In 37.1% (23/62) of cases, both methods showed identical results, whereas in 43.5% (27/62) of cases, the samples were positive by both methods, but SMg found additional species in 88.9% (24/27), mostly anaerobes. When the standard approaches were negative, the SMg was able to detect microorganisms in 80.0% of cases (8/10). Overall, SMg identified significantly more microorganisms than culture (414 vs.105; p<0.05). K. pneumoniae genome analysis was able to detect resistance and virulence genes with a level of sensitivity depending on the depth of sequencing.

DISCUSSION

Overall, we showed that SMg had better performance in detecting and identifying microorganisms from LA samples and could help characterizing strain's resistome and virulome. Although still costly and requiring specific skills and expensive equipment, MGs methods are set to expand in the future.

Management of Pyogenic Liver Abscesses: Contemporary Strategies and Challenges

Pyogenic liver abscesses (PLAs) are a suppurative infection of the hepatic parenchyma responsible for significant morbidity and mortality. PLAs are categorized into a variety of mechanisms: (1) via the portal vein, (2) through the biliary tract, (3) via the hepatic artery, (4) from trauma, (5) contiguously via direct extension, and (6) cryptogenically. The pathogenesis of PLA, which informs treatment, can often be discerned based on host factors, clinical presentation, and causative microorganisms. The Streptococcus anginosus group, hypervirulent Klebsiella pneumoniae , and multidrug-resistant gram-negative pathogens have emerged as microbiologically challenging organisms to treat. The identification of hypervirulent K. pneumoniae should prompt for assessment for metastatic spread and consideration of prolonged antimicrobial treatment. Abdominal imaging is indispensable in characterizing PLAs and facilitating source control interventions. Source control remains the most critical aspect of PLA management, followed by antimicrobial therapy. Empiric antibiotics for PLAs are informed by the suspected etiology of PLA formation. Duration of antimicrobial therapy is individualized and dependent on multiple components, including the success of achieving source control, host factors, mechanism of PLA development, and the illness course of the individual-factoring in clinical, biochemical, and radiographic parameters.

[Clinical and radiological differences between amoebic and pyogenic liver abscess: A case-control study]

INTRODUCTION

Amoebic liver abscess (ALA) is the fourth cause of mortality by parasitic infection. This study aimed to assess clinical, radiological and therapeutic characteristics of patients admitted for amoebic liver abscess compared to pyogenic abscess in a French digestive tertiary care-centre.

MATERIAL AND METHOD

The charts of patients hospitalized for a liver abscess between 2010 and 2020 were retrospectively assessed then separated in two groups: amoebic liver abscess and pyogenic liver abscess from portal underlying cause. Clinical and radiological data were collected for univariate comparison.

RESULTS

Twenty-one patients were hospitalized during the time of the study for ALA, and 21 patients for pyogenic liver abscess with a portal mechanism. All patients hospitalized for ALA lived in and/or had travelled recently in an endemic area. In comparison with patients hospitalized for pyogenic abscess, patients admitted for ALA were younger (44years old vs. 63years old, P<0.001), had less comorbidities (5% vs. 43% of patients with at least one comorbidity, P<0.01), a longer median duration of symptoms (10days vs. 3days, P=0.015), abdominal pain (86% vs. 52%, P=0.019), and a slighter leucocytosis (9600G/L vs. 15,500G/L, P=0.041) were more frequent. On the abdominal tomodensitometry, density of ALA was higher (34 vs. 25 UH, P<0.01), associated with a focal intra-hepatic biliary dilatation and less often multiloculated.

CONCLUSION

While rare in western countries, amoebic liver abscess care should not be underestimated. The presence of a solitary liver abscess of intermediate density on computed tomography, occurring on a patient returning from an endemic zone should lead the physician to a possible diagnosis of ALA.

A Population-Based Study of Unfavorable Prognostic Factors Associated With Pyogenic Liver Abscess

Background

Pyogenic liver abscess (PLA) is a rare entity that is associated with substantial mortality and morbidity. Our objective was to investigate variables associated with mortality and subsequent PLA in patients diagnosed with PLA in southern Sweden.

Methods

We conducted a population-based observational study comprising all episodes of PLA that occurred between 2011 and 2020 in the county of Skåne, southern Sweden. The primary outcome was defined as all-cause 90-day mortality and the secondary outcome was defined as the occurrence of a subsequent PLA.

Results

A total of 452 episodes of PLA occurred in 360 patients during the study period. The 90-day mortality rate was 16% (n = 58) and the subsequent PLA rate was 20% (n = 92). In a multivariable logistic regression model, female sex (odds ratio [OR], 2.0 [95% confidence interval {CI}, 1.1-3.9]), malignancy (OR, 3.7 [95% CI, 1.9-7.1]), liver failure (OR, 6.3 [95% CI, 2.7-14.5]), and polymicrobial findings (OR, 3.8 [95% CI, 2.2-6.9]) were associated with death within 90 days (P < .05). Male sex (OR, 2.1 [95% CI, 1.2-3.6]), malignancy (OR, 2.1 [95% CI, 1.3-3.6]), age (64-74 years: OR, 2.5 [95% CI, 1.3-4.8]), and chronic liver disease (OR, 3.0 [95% CI, 1.4-6.5]) were associated with the risk of subsequent PLA (P ≤ .01).

Conclusions

Identifying different clinical variables associated with an unfavorable outcome may improve the management and treatment of patients with PLA and thus prevent the risk of death and subsequent PLA.