Prognostic Factors and Visual Outcomes of Pyogenic Liver Abscess-Related Endogenous Klebsiella pneumoniae Endophthalmitis: A 20-year retrospective review

Risk Factors for Legal Blindness in 237 Japanese Patients with Exogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential risk factors for visual prognosis in Japanese patients with exogenous endophthalmitis.

METHODS

In this retrospective observational multicenter cohort study, risk factors for legal blindness at 12 weeks after treatment initiation were evaluated based on patient characteristics, initial BCVA, causative events, pathogens, ocular symptoms, duration from symptom onset to initial treatment, and selected treatments.

RESULTS

Overall, 23.1% of eyes developed legal blindness. The six risk factors for legal blindness were presence of eye pain, pathogen identification, poor BCVA at the initial visit, longer duration from symptom onset to initial treatment, type of causative event, and type of causative pathogen. Regarding the type of causative pathogen, coagulase-negative staphylococci was associated with a better visual impairment outcome.

CONCLUSION

Exogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatment, as well as other advances in medical knowledge and technology.

Klebsiella pneumoniae Endophthalmitis with Subretinal Abscess: A Case Series and Review of the Literature

This study assessed prognostic factors and the role of vitrectomy in patients with subretinal abscesses secondary to K. pneumoniae endophthalmitis. We reviewed published studies, including three cases from our cohort. Among 50 eyes, 26 had poor visual outcomes (final visual acuity <20/800, eyeball removal, or phthisis bulbi). Poor outcomes correlated with delayed ocular symptom-to-diagnosis time, initial visual acuity <20/800, severe vitritis, and macular involvement of abscesses (p < 0.001, p = 0.008, p < 0.001, and p = 0.033, respectively). Vitrectomy had a trend towards reducing eyeball removal and phthisis bulbi rates compared with non-vitrectomy (10.8% vs 30.8%, p = 0.181). However, the final visual acuity was not different and the rate of retinal detachment tended to be higher in vitrectomized eyes (45.9% vs 15.4%, p = 0.095). The study suggested that vitrectomy and drainage of K. pneumoniae subretinal abscesses could be avoided in patients with a mild degree of vitritis.

Bilateral Endogenous Bacterial Endophthalmitis with Asynchrony for 14 Months due to Klebsiella pneumoniae: A Case Report

Introduction

The aim of this study was to describe a very rare case of endogenous bacterial endophthalmitis caused by Klebsiella pneumoniae in both eyes with a difference in the onset of symptoms of 14 months in an immunocompetent patient.

Case Presentation

A 66-year-old immunocompetent man presented with asynchronous bilateral endogenous endophthalmitis produced by the K. pneumoniae bacterium at the starting point of a liver abscess after cholecystectomy surgery, causing endophthalmitis 1 year and 2 months apart between an eye and another. The first was diffuse anteroposterior endophthalmitis in the left eye that ended in visual loss and phthisis bulbi due to delayed initial diagnosis and established treatment, and the second was focal endophthalmitis in the right eye that preserved the organ and resulted in a vision of 20/20 due to early suspected diagnosis and rapid instituted treatment.

Conclusion

To our knowledge, this is the first published case of a long asynchronous bilateral endogenous bacterial endophthalmitis caused by K. pneumoniae with a prolonged difference of 14 months in the onset of symptoms between one eye and another. This case is a vision-threatening ophthalmologic emergency that can be associated with life-threatening systemic morbidities. The early diagnosis of infection represents a challenge for clinicians, ophthalmologists, and microbiologists.

A retrospective study of endogenous endophthalmitis-related pyogenic liver abscess: An increasing complication in North Vietnam

Introduction

Endogenous endophthalmitis-related Klebsiella pyogenic liver abscess is a rare complication of metastatic infection. In most cases, visual acuity results are often impaired, even blind, and even with aggressive treatment with topical antibiotics, the final results are unsatisfactory. The objective of this study is to retrospectively based on medical records to describe clinical features, risk factors, and visual outcomes of patients with endogenous endophthalmitis-related pyogenic liver abscesses.

Methods

We reported a case series of 12 endogenous endophthalmitis-related pyogenic liver abscess patients from March 2021 to 2023. All cases of endogenous endophthalmitis were diagnosed at admission or during the hospital stay.

Results

From the medical records of 588 pyogenic liver abscess patients, we found 12 cases of endogenous endophthalmitis with 2.0%. The result showed a mean age of 61.5 ± 12.0 (41-78), diabetes mellitus (7 of 12), right lobe (7 of 12), single abscess (9 of 12), and the mean largest abscess diameter of 5.8 ± 1.7 cm (3.3-9). All patients had ocular symptoms such as eye pain (9 of 12), pus discharge (3 of 12), hypopyon (1 of 12), swollen eyelids (2 of 12), and corneal edema (2 of 12), pyogenic liver abscess before endogenous endophthalmitis (10 of 12), the median interval between endogenous endophthalmitis and pyogenic liver abscess 6.1 ± 1.9 days, ocular symptoms before diagnosis endogenous endophthalmitis 4.4 ± 2.3 days. All affected eyes were injected intravitreously with ceftazidime, amikacin, and vancomycin. Two patients underwent evisceration.

Conclusions

Endogenous endophthalmitis has permanent morbidity, reducing visual acuity, poor quality of life, and lacks the warning signs, so it is essential for early detection of symptoms and referral to ophthalmologists.

Consensus and controversies in the science of endophthalmitis management: Basic research and clinical perspectives

Infectious endophthalmitis is a severe intraocular infection caused by bacteria, or less commonly by fungi. It can occur after penetrating eye procedures, trauma, or the spread of infection from contiguous structures or via emboli from distant organs. Because of the time-critical nature of the treatment, endophthalmitis is treated with the clinical diagnosis and modified by the microbiological report of the intraocular contents. The current strategy for managing endophthalmitis relies on pre-clinical literature, case series, and one large multi-center randomized clinical trial on post-cataract surgery endophthalmitis. Culture-susceptibility of the microorganisms from undiluted vitreous guides the definitive treatment in non-responsive cases. Strategies to reduce the incidence of endophthalmitis after penetrating eye procedures have been developed concurrently with refined means of treatment. Despite these advances, outcomes remain poor for many patients. Although consensus articles have been published on managing endophthalmitis, treatment patterns vary, and controversies remain. These include (1) the use of newer methods for early and precise microbiological diagnosis; (2) the choice of intravitreal antibiotics; (3) the need for systemic therapy; (4) early and complete vitrectomy. Here, we review the current consensus and address controversies in diagnosing and managing endophthalmitis. This review is intended to familiarize physicians and ophthalmologists with different aspects of endophthalmitis management to make informed decisions.

Risk Factors for Legal Blindness in 77 Japanese Patients with Endogenous Endophthalmitis: A Multicenter Cohort Study from J-CREST

PURPOSE

We investigated potential predictive factors for visual prognosis in Japanese patients with endogenous endophthalmitis.

DESIGN

Retrospective observational multicenter cohort study.

METHODS

We examined the characteristics of 77 Japanese patients with endogenous endophthalmitis and performed statistical analyses of these real-world data. The primary endpoint was the identification of factors associated with visual prognosis. We examined differences between patients in the better vision and legal blindness groups at 12 weeks after treatment initiation.

RESULTS

The five risk factors for visual impairment at 12 weeks after treatment initiation were presence of pressure injuries, severe clinical symptoms (presence of eye pain and ciliary injection), pathogen identification, and poor best-corrected visual acuity at baseline. Staphylococcus aureus and fungus were associated with a better visual impairment outcome.

CONCLUSIONS

Endogenous endophthalmitis remains a severe ocular infection; however, it can be managed with rapid treatments, as well as other advances in medical knowledge and technology.

Endogenous Endophthalmitis From a Klebsiella pneumoniae Liver Abscess: The Incidence, Risk Factors, and Utility of Imaging

PURPOSE

We investigated the rate of ophthalmologic examinations to detect endogenous endophthalmitis in patients with pyogenic liver abscesses (PLAs) and the incidence and risk factors of endophthalmitis from a PLA caused by Klebsiella pneumoniae (PLA-K).

DESIGN

Retrospective case series.

METHODS

A total of 536 patients admitted to a university hospital in Korea to treat PLAs during 2012-2022 were included. The proportion of patients who were referred for ophthalmologic examinations was investigated and the incidence of endophthalmitis in 248 patients with PLA-K was calculated. Univariate and multivariate logistic regression analyses were performed to define risk factors including demographic characteristics, underlying diseases, radiologic findings, and systemic conditions.

RESULTS

A comprehensive ophthalmologic examination was performed in 73.7% of all patients with PLAs, and the incidence of endophthalmitis from a PLA-K was 7.3%. A liver abscess >5 cm increased the incidence of endogenous endophthalmitis 4-fold compared with smaller abscesses (odds ratio [OR] = 4.01 [95% confidence interval {CI}, 1.02-15.78], P = .047) and portal or hepatic vein thrombophlebitis increased the incidence approximately 4-fold (OR = 4.04 [95% CI, 1.10-14.83], P = .036). Acute cholangitis was approximately 8-fold (OR = 8.33 [95% CI, 1.25-55.71], P = .029), and disseminated intravascular coagulation was approximately 6-fold (OR = 5.76 [95% CI, 1.22-27.21], P = .027) more related to prevalence of endophthalmitis. Other extrahepatic infections increased the incidence approximately 43-fold (OR = 43.06 [95% CI, 10.14-182.90], P < .001).

CONCLUSIONS

Clinicians should consider the risk of endogenous endophthalmitis when PLA-K patients have large liver abscesses (>5 cm), acute cholangitis, portal or hepatic vein thrombophlebitis, disseminated intravascular coagulation, or other extrahepatic infections.

Klebsiella Endogenous Endophthalmitis During the COVID-19 Pandemic

Purpose: To describe the characteristics of Klebsiella pneumoniae endogenous endophthalmitis (KEE) encountered during the COVID-19 pandemic. Methods: This retrospective consecutive case series evaluated eyes that presented with KEE between March 2020 and July 2022. Results: Seven eyes of 5 patients developed KEE. Between January 2020 and July 2022, KEE was observed in 42% of consecutive EE cases compared with 7.8% during the preceding 13 years. COVID-19 was positive in 4 of 5 patients before they developed KEE. Only 1 patient presented with a VA better than hand motions (20/400). All eyes were treated with urgent vitrectomy and intravitreal and systemic antibiotics. No improvement in vision occurred in any patient; VA remained light perception to no light perception in 60% of eyes. Conclusions: The visual prognosis in KEE is extremely poor. The presence of a preceding COVID-19 infection in 80% of patients may signal a new risk factor for KEE. Patients with a hypervirulent Klebsiella syndrome should be routinely screened for EE.

Pyogenic liver abscess complicated with endogenous endophthalmitis caused by Klebsiella pneumoniae: A case report and Literature Review

OBJECTIVE

Pyogenic liver abscess (PLA) is a common surgical infectious disease caused by various pathogens. Klebsiella pneumoniae is a relatively recent cause, often affecting patients with low immunity. Endogenous endophthalmitis (EE), a rare and serious complication of PLA, may appear with eye symptoms before PLA. By reviewing a case of Klebsiella pneumoniae-induced PLA complicated with EE, we want to summarize the information about the characteristics, causes, and complications of PLA based on the literature review.

METHODS

This case report describes a 37-year-old male who had fever high to 39°C for 10 days experienced blurred vision followed by nonlight perception vision. He reported a history of diabetes irregularly taking oral medications and insulin therapy. Imaging examination found a large low-density area in the right lobe of the liver with an unclear border and vague surrounding fat gap. The blood culture was not positive. The culture of the drainage fluid from the liver puncture showed Klebsiella pneumonia. Blood and liver puncture drainage fluid were sent for microbial high-throughput gene detection with next-generation sequencing technology (NGS), which confirmed the diagnosis of Klebsiella pneumoniae-induced PLA complicated with EE.

RESULTS

The patient's surgical incision had healed well at discharge, and he could feel light at his left eye. But the patient was lost to follow-up since the third month after discharge.

CONCLUSION

By reviewing this case and summarize the information about the characteristics, causes, and complications of PLA based on the literature review, we concluded that it is necessary to promptly perform liver puncture drainage and empirically use antibiotics for patients with PLA, especially those with poor glycemic control, to avoid serious complications such as EE.

CONCOMITANT PYOGENIC LIVER AND INTRAOCULAR ABSCESSES IN KLEBSIELLA ENDOGENOUS ENDOPHTHALMITIS: CASE REPORT AND REVIEW OF LITERATURE

PURPOSE

To describe a rare presentation of Klebsiella pneumoniae endogenous endophthalmitis with concurrent intraocular and liver abscesses.

METHODS

Case Report.

RESULTS

A middle-aged man presented with a red and painful eye with a preceding febrile gastrointestinal illness. Examination and work-up revealed concomitant intraocular and liver abscesses that were treated by pars plana vitrectomy, drainage of subretinal abscess, inpatient admission, and systemic antibiotics. The patient ultimately underwent enucleation of the eye because of persistent pain and poor visual prognosis.

CONCLUSION

Klebsiella pneumoniae endogenous endophthalmitis is a rare and potentially devastating disease that requires high clinical suspicion and early diagnosis. Practitioners should consider systemic etiologies and communicate guarded prognoses in this serious systemic disease.

Endogenous Endophthalmitis and Liver Abscess: A Metastatic Infection or a Coincidence?

Klebsiella pneumoniae is a gram-negative pathogen that is a common cause of severe infections, including pyogenic liver abscess. Dissemination of K. pneumoniae to other organs, including the eye, is associated with significant morbidity and mortality. In the particular case of endogenous endophthalmitis (EE) by K. pneumoniae the prognosis is poor. We report the case of a middle-aged female with K. pneumoniae liver abscess. The patient developed metastatic endophthalmitis that was aggressively treated with systemic antibiotics. The liver abscess resolved with antimicrobials and percutaneous transhepatic drainage, but regarding the endophthalmitis she was discharged from our hospital without recovery of her eyesight. Metastatic spread to the eye should be considered in all patients with liver abscesses who experience ocular signs and symptoms in order to establish a timely diagnosis of EE.

Infection Sources and Klebsiella pneumoniae Antibiotic Susceptibilities in Endogenous Klebsiella Endophthalmitis

Endogenous endophthalmitis is an uncommon intraocular infection with potentially devastating consequences on vision. Klebsiella pneumoniae is highly prevalent in East Asian countries, with an increasing incidence recently worldwide. This retrospective study investigates infection sources and antibiotic susceptibilities of K. pneumoniae in patients with endogenous K. pneumoniae endophthalmitis (EKE) in Northern Taiwan. One hundred and fifty-seven patients with EKE were reviewed between January 1996 and April 2019. Pyogenic liver abscess (120/157, 76.4%) was the most common infection source, followed by pneumonia (13, 8.3%), urinary tract infection (7, 4.5%), and intravenous drug use (4, 2.5%). Bilateral involvement was identified in 12.1% (19/157) of patients, especially in patients with pyogenic liver abscess (16/120, 13.3%), pneumonia (2/13, 15.4%), and urinary tract infection (1/7, 14.3%). The antibiotic susceptibility rates were 98.1%, 92.5%, 97.5%, 96.8%, 100%, 99.3%, and 100% for amikacin, cefuroxime, ceftazidime, ceftriaxone, carbapenems, ciprofloxacin, and levofloxacin, respectively. Four extended-spectrum β-lactamase-producing multidrug-resistant (MDR) K. pneumoniae isolates were identified. In conclusion, pyogenic liver abscess was the major infection source in EKE. In addition, K. pneumoniae was still highly susceptible to ceftazidime and amikacin, and the MDR K. pneumoniae isolates were not common in EKE.

Endogenous Fungal Endophthalmitis: Causative Organisms, Treatments, and Visual Outcomes

Endogenous fungal endophthalmitis (EFE) is a vision-threatening intraocular infection and a rare complication of fungemia. Early diagnosis and prompt aggressive treatment are crucial to avoid vision loss. We retrospectively reviewed the data of 37 patients (49 eyes) with EFE who were treated at a tertiary referral hospital from January 2000 to April 2019. The most common risk factor was diabetes (24 patients; 65%), followed by recent hospitalization, urinary tract disease, liver disease, and immunosuppressive therapy. Two or more risk factors were detected in 24 patients (65%), and yeasts (29 patients; 78%) were more commonly detected than mold (8 patients; 22%). The most common fungal isolates were Candida spp. (78%), especially Candida albicans (70%). Moreover, 24 eyes in 21 patients underwent vitrectomy, and 2 eyes underwent evisceration. Retinal detachment (RD) occurred in 17 eyes (35%) in 14 patients, and eyes without RD exhibited significantly superior visual outcomes (p = 0.001). A comparison of the initial VA between the better (20/200 or better) and worse groups (worse than 20/200) revealed that better initial VA was related to a superior visual outcome (p = 0.003). Therefore, to achieve superior visual outcomes, early diagnosis and prompt treatment are necessary for patients with EFE.

The Noxious Intruder of the Eye: Endogenous Klebsiella Panophthalmitis

Endogenous Klebsiella pneumoniae panophthalmitis commonly affects those with compromised immunity. The occurrence of this infection in healthy individuals is rare. We describe the case of a healthy adult who presented with endogenous Klebsiella pneumoniae panophthalmitis from an asymptomatic liver abscess.

A 64-year-old, previously healthy gentleman presented with rapidly progressive left eye periorbital swelling and blurring of vision. He had a low-grade fever three days prior to the development of ocular symptoms, but otherwise no other systemic complaints. Visual acuity was light perception in the left eye, and ocular motility was restricted in all directions of gaze. Ocular examination revealed proptosis, severe conjunctival chemosis, hazy cornea, and fibrin deposition in the anterior chamber. The posterior segment could not be visualized.

Ultrasound of the hepatobiliary system revealed an abscess in the right lobe of his liver. His blood cultures grew Klebsiella pneumoniae. Despite being treated with high-dose intravenous antibiotics, his eye condition deteriorated. Evisceration was performed when he developed scleral melting and globe perforation.

We highlight the importance of a high index of suspicion of endogenous Klebsiella panophthalmitis as it can be easily missed in healthy adults. Early diagnosis and prompt management are needed to prevent morbidity and mortality from this devastating infection.

Clinical comparison of febrile and afebrile patients with pyogenic liver abscess: A two-centre retrospective study

BACKGROUND

: Limited research has been conducted on afebrile pyogenic liver abscess (PLA). This poses a challenge in rapid diagnosis and early tailored care to physicians. In his study, we aimed to compare the clinical characteristics of afebrile and febrile patients with PLA.

METHODS

: We retrospectively analyzed the data of patients with PLA who were admitted to the emergency departments of two university hospitals between January 2014 and March 2020. Patients were classified into afebrile and febrile groups by using body temperature higher than 38°C as the reference standard. The demographic, clinical, and laboratory characteristics of both groups were compared. The primary outcome was all-cause in-hospital mortality and length of hospital stay. Multivariate analysis was performed to define factors associated with afebrile PLA.

RESULTS

: Of the 239 patients included in this study, 51 patients (21.3%) were afebrile and 188 patients (78.7%) were febrile. There were no differences between the abscess characteristics, laboratory manifestations, and disease severity of both groups; however, age and Charlson score differed between the groups (P = 0.009 and P = 0.011). The all-cause in-hospital mortality rate was much higher in the afebrile PLA group than in the febrile PLA group (9.8% vs. 2.1%, P = 0.011). Regarding the length of stay, no significant differences were noted in the febrile PLA group compared with the afebrile PLA group (18.5% vs 17.3%, P = 0.514). In multivariate analyses, only age greater than 65 years was significantly associated with afebrile PLA.

CONCLUSIONS

: Afebrile patients with PLA tend to be older, have higher Charlson scores, and in-hospital mortality rate than those with febrile patients. PLA patients older than 65 years are more likely to present without fever (<38°C) at the time of the emergency visit.

Susceptibility of bacterial endophthalmitis isolates to vancomycin, ceftazidime, and amikacin

Bacterial endophthalmitis is a rare intraocular infection, and prompt administration of intravitreal antibiotics is crucial for preventing severe vision loss. The retrospective study is to investigate the in vitro susceptibility to the antibiotics vancomycin, amikacin, and ceftazidime of bacterial endophthalmitis isolates in specimens at a tertiary referral center from January 1996 to April 2019 in Taiwan. Overall, 450 (49.9%) isolates were Gram positive, 447 (49.6%) were Gram negative, and 4 (0.4%) were Gram variable. In Gram-positive isolates, coagulase-negative staphylococci were the most commonly cultured bacteria (158, 35.1%), followed by Streptococci (100, 22.2%), Enterococci (75, 16.7%), and Staphylococcus aureus (70, 15.6%). In Gram-negative isolates, they were Klebsiella pneumoniae (166, 37.1%) and Pseudomonas aeruginosa (131, 29.3%). All Gram-positive organisms were susceptible to vancomycin, with the exception of one Enterococcus faecium isolate (1/450, 0.2%). Of the Gram-negative isolates, 96.9% and 93.7% were susceptible to ceftazidime and amikacin, respectively. Nine isolates (9/447, 2.0%) were multidrug-resistant Gram-negative bacteria, comprising K. pneumoniae (4/164, 2.4%), Acinetobacter baumannii (2/3, 67%), and Stenotrophomonas maltophilia (3/18, 17%). In conclusion, in vitro susceptibility testing revealed that vancomycin remains the suitable antibiotic treatment for Gram-positive endophthalmitis. Ceftazidime and amikacin provide approximately the same degree of Gram-negative coverage. Multidrug-resistant bacterial endophthalmitis was uncommon.

Case Series on Endogenous Klebsiella pneumoniae Endophthalmitis: More Than Meets the Eye

Endogenous endophthalmitis (EE) is a rare but potentially sight-threatening disease with an appreciable mortality rate. Diabetes mellitus remains the most frequently associated condition especially in the Asian population, which potentiates Klebsiella pneumoniae involvement. Endogenous Klebsiella pneumoniae endophthalmitis (EKE) usually has a poor final visual outcome despite treatment with intravitreal and systemic antibiotics. We report three cases of EKE with systemic involvement Klebsiella pneumoniae invasive syndrome (KPIS). KPIS was diagnosed in three patients with multiple comorbidities who presented with a blurring of vision and eye redness. Patient 1 was a 63-year-old Malay man diagnosed with left eye panophthalmitis with multifocal liver and prostate abscesses. He underwent drainage of the liver abscess and eventually evisceration of the left eye due to scleral perforation. Patient 2 was a 66-year-old Malay woman diagnosed with left eye endophthalmitis. Due to hemodynamic instability, vitrectomy was delayed and eventually sustained corneal perforation and eviscerated. The patient eventually succumbed to infection. Patient 3 was a 42-year-old Malay woman diagnosed with KPIS, renal abscess, lung abscess, and left endogenous endophthalmitis. She underwent a vitrectomy but her postoperative vision remained poor. All patients received multiple intravitreal antibiotics and systemic antibiotics. KPIS is frequently associated with catastrophic disabilities. Our cases highlight the importance of an early suspicion of systemic involvement in patients presenting with EKE. Prompt diagnosis, emergent radiographic evaluation, early adequate drainage, and appropriate treatment with antibiotics potentially improve survival and visual prognosis.

Does Endogenous Endophthalmitis Need a More Aggressive Treatment?

Topic: To focus on endogenous endophthalmitis management, particularly etiology-based medical and surgical therapy.Methods: Literature search of published studies from July 1990 to February 2019 on endogenous endophthalmitis available on PubMed was made without any language constraints.Results: A total of 78 articles were retrieved from 728 initially analyzed and 62 studies were included. Although the superiority of vitrectomy over tap and inject techniques is controversial, the most recent publications favor an early surgical approach for endogenous endophthalmitis. Vitrectomy is useful in severe cases complicated by marked vitreous opacity, retinal detachment, poor initial visual acuity, and more virulent pathogens. Oral or intravenous antibiotics are also necessary to treat systemic infection. Vitrectomy is superior to blood cultures in diagnosing the etiology of infection.Conclusions: Endogenous endophthalmitis is an important cause of visual acuity impairment. Prompt treatment with appropriate use of pharmacological or surgical therapy is mandatory to preserve visual function.Abbreviations: IOP: intra-ocular pressure; AIDS: acquired immune deficiency syndrome; EVS: endophthalmitis vitrectomy study; CEVE: complete and early vitrectomy for endophthalmitis.

Utility of Acute Physiology and Chronic Health Evaluation (APACHE II) in Predicting Mortality in Patients with Pyogenic Liver Abscess: A Retrospective Study

Pyogenic liver abscess (PLA) is a major life-threatening disease with varied clinical features. This study aimed to determine predictors of mortality in patients with PLA using criteria determined upon admission. We retrospectively examined the data of 324 hospitalized adults in whom liver abscesses were confirmed using abdominal ultrasound and/or computed tomography. The relationship between various risk factors was assessed using multivariate analysis. A total of 109 (33.6%) patients were admitted to the intensive care unit (ICU). The overall mortality rate was 7.4% and was higher among ICU patients than non-ICU patients (21.1% vs. 0.5%, p < 0.001). PLA patients with an Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥18 had a 19.31-fold increased risk, and those with concomitant infections had a 34.33-fold increased risk of 30-day mortality according to multivariate analysis. The estimated area under the receiver operating characteristic curve for predicting 30-day mortality revealed that APACHE II score ≥18 (sensitivity of 75% and specificity of 84%, p < 0.0001) had better discriminative power than Sequential Organ Failure Assessment (SOFA) ≥6 (sensitivity of 81% and specificity of 66%, p < 0.0001). APACHE II has shown better discrimination ability than SOFA in predicting mortality in PLA patients. To improve outcomes in patients with PLA, future management strategies should focus on high-risk patients.

Importation of Entamoeba histolytica and predominance of Klebsiella pneumoniae in liver abscesses: a 7-year retrospective cohort study from the United Arab Emirates

BACKGROUND

There is a dearth of information on liver abscesses in the United Arab Emirates. Herein, we describe the clinical features of liver abscesses and determine their incidence rates and clinical outcomes.

METHODS

We retrospectively reviewed the clinical charts of adult patients with a primary diagnosis of liver abscess at a major hospital over a 7-year period.

RESULTS

Amongst 45 patients, 82.2% (37/45) had a pyogenic liver abscess (PLA) and 17.8% (8/45) had amoebic liver abscesses (ALA). Overall, patients were young (median age 42 years, IQR 35-52), mostly males (77.8%, 35/45) from the Indian subcontinent (55.6%, 25/45), presented with fever (88.9%, 40/45) and abdominal pain (88.9%, 40/45), and had a solitary abscess on imaging (71.1% (32/45). Crude annual incidence rates were 35.9/100,000 hospital admissions (95% CI 26.2-48.0) and 5.9/100,000 inhabitants (95% CI 4.3-7.9). All ALA patients were from the Indian subcontinent (100%, 8/8). Klebsiella pneumoniae was the most frequent pathogen in PLA (43.2% [16/37], 95% CI 27.1-60.5%). The hospital stay was shorter in ALA (7.5 days, IQR 7-8.5) than in PLA (14 days, IQR 9-17). No deaths were recorded within 30 days of hospitalisation.

CONCLUSIONS

ALA was exclusively seen in migrants from the Indian subcontinent, suggesting importation. Further research to characterise K. pneumoniae isolates and assess potential risk factors is needed.

Clinical Characteristics and Outcomes in 314 Japanese Patients with Bacterial Endophthalmitis: A Multicenter Cohort Study from J-CREST

Bacterial endophthalmitis is an intraocular infection that causes rapid vison loss. Pathogens can infect the intraocular space directly (exogenous endophthalmitis (ExE)) or indirectly (endogenous endophthalmitis (EnE)). To identify predictive factors for the visual prognosis of Japanese patients with bacterial endophthalmitis, we retrospectively examined the bacterial endophthalmitis characteristics of 314 Japanese patients and performed statistics using these clinical data. Older patients, with significantly more severe clinical symptoms, were prevalent in the ExE group compared with the EnE group. However, the final best-corrected visual acuity (BCVA) was not significantly different between the ExE and EnE groups. Bacteria isolated from patients were not associated with age, sex, or presence of eye symptoms. Genus Streptococcus, Streptococcus pneumoniae, and Enterococcus were more prevalent in ExE patients than EnE patients and contributed to poor final BCVA. The presence of eye pain, bacterial identification, and poor BCVA at baseline were risk factors for final visual impairment.

Clinical features and treatment outcomes of endogenous Klebsiella endophthalmitis: a 12-year review

AIM

To identify the clinical features and treatment outcomes of endogenous Klebsiella pneumoniae endophthalmitis and investigate prognostic factors of poor visual outcome.

METHODS

The clinical records of all patients diagnosed with endogenous Klebsiella endophthalmitis between January 2007 to December 2018 in Prince of Wales Hospital, Hong Kong, China were retrospectively reviewed. Thorough ophthalmological examination findings were recorded in the case note, including visual acuity testing, slit-lamp examination, indirect ophthalmoscopy and B-scan ultrasonography if media opacity precluded fundus viewing.

RESULTS

A total of 18 eyes in 14 patients were identified. Bilateral involvement was noted in 4 patients (28.6%). Hepatobiliary sepsis was the source in 9 patients (64.3%). Culture of intraocular fluid was positive in 5 out of 18 eyes (27.8%). Mortality was noted in 2 patients (14.3%). Mean final visual acuity was 20/1500. Six out of 16 eyes had total loss of sight (37.5%) and 3 eyes required evisceration (18.8%). Multivariate linear regression revealed poor presenting visual acuity (P=0.031) and lack of fundus view due to vitritis (P=0.02) as prognostic factors of poor visual outcome.

CONCLUSION

Visual outcome of endogenous Klebsiella endophthalmitis is poor. Poor presenting visual acuity and lack of fundus view predict poor visual outcome. High index of suspicion for endophthalmitis is important in Klebsiella sepsis patients with complaints of ocular symptoms. Ophthalmological screening is recommended in non-communicable patients with Klebsiella sepsis.

Endogenous Endophthalmitis: A Review of Case Series Published between 2011 and 2020

This is a literature review of 31 case series of endogenous endophthalmitis (EE) published in the last ten years, identified from a literature search of several databases (PubMed, EMBASE, and the Cochrane Library). While diabetes mellitus and malignancies remain the most frequently associated medical conditions, intravenous drug use is a significant risk factor (especially in the last years, in studies from Western countries). Ophthalmologic screening is recommended for candidaemia, but not in patients with sepsis of other aetiologies (however, the physician treating patients with sepsis must be well aware of EE). The most frequent Gram-positive microorganisms that cause EE are Staphylococcus and Streptococcus; the most frequent Gram-negative organism is Pseudomonas, and yeasts, probably Candida, usually cause fungal infections. In all-cause EE, prognostic factors of better visual outcomes are initial VA better than counting fingers, performing a pars plana vitrectomy (PPV), performing an intravitreal injection within the first 24 hours after clinical diagnosis, and the presence of a focal type of EE. In endogenous fungal endophthalmitis, more than 1/4 of patients have bilateral involvement. Blood samples have a low rate of positivity. Yeasts remain the most prevalent cause. Many authors report using azoles and echinocandins for systemic therapy (and voriconazole for intravitreal injections). Although PPV was performed in small proportions of eyes, the anatomical success rate is quite high. Klebsiella pneumoniae is an important cause of EE in Southeast Asia (and probably an emergent etiology in other regions), which is frequently associated with diabetes. There is a robust association with pyogenic liver abscess (PLA) (but in up to half of the cases, the diagnosis of EE precedes that of PLA). Blood cultures have a high diagnostic yield, while vitreous samples have a low yield. K. pneumoniae may carry antibiotic resistance. Anatomical and functional success rates are small, but they may be improved with PPV.

Endogenous endophthalmitis in Klebsiella pneumoniae pyogenic liver abscess: Systematic review and meta-analysis

BACKGROUND

Endogenous endophthalmitis (EE) is a devastating complication that develops as a metastatic infection in patients with Klebsiella pneumoniae pyogenic liver abscess (KPPLA). The existing data are heterogeneous and the actual disease burden and risk factors for the development of EE among patients with KPPLA have not been systematically examined. We performed a systematic review and meta-analysis to examine the incidence of EE, temporal trend of EE, and risk factors for EE in patients with KPPLA.

METHODOLOGY

The MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were searched for articles published from inception to 2020 that evaluated the incidence of EE among patients with KPPLA. By a random-effects method, a pooled estimate of its incidence with 95% confidence intervals was estimated along with examination of its temporal and geographic variations. Pooled odds ratios were calculated for risk factors.

RESULTS

Fifteen retrospective studies reporting data on 11889 patients with KPPLA met the inclusion criteria and were analyzed. With 217 patients developing EE, the pooled incidence of EE was 4.5% (95% confidence interval 2.4% to 8.2%). The heterogeneity was considerable and significant (Cochran's Q 243.5, p < 0.001, I² = 94.2%).

CONCLUSION

This meta-analysis estimates the actual incidence of EE among patients with KPPLA, where EE is reported in about 1 of 22 patients with KPPLA. Infection caused by K1 capsular serotype was an independent risk factor.

Surgery combined with antibiotics for the treatment of endogenous endophthalmitis caused by liver abscess

Backgrounds

Endogenous endophthalmitis is a serious disease caused by intraocular infection that can rapidly progress to cause blindness. This study evaluated the clinical features, surgical and antibiotics treatment strategies, and treatment outcomes in patients with endophthalmitis caused by liver abscess.

Methods

Between April 2014 and April 2019, the clinical data of 16 patients (19 eyes) with endophthalmitis associated with liver abscess who underwent surgery at Shengjing Hospital were retrospectively analyzed. Furthermore, we evaluated the final visual outcomes in the patients to determine the efficacy of surgery.

Results

Fifteen patients (18 eyes) underwent intravitreal injection followed by vitrectomy after admission. One patient (1 eye) only underwent intravitreal injection. Of the 16 patients, 3 patients (3 eyes) had recurrent intraocular inflammation and eventually underwent evisceration. Systemic antibiotics were administered for all patients based on the results of vitreous humor culture, blood culture, and antibiotic susceptibility tests. Outpatient follow-ups were performed until the patients were stable (6 months). Of the 19 eyes, 1 eye (5%) had visual acuity restored to 20/200, 6 eyes (31%) had visual acuity restored to counting fingers (CF), 2 eyes (11%) had visual acuity restored to hand motion (HM), 4 eyes (22%) showed only light perception (LP), and the remaining 6 eyes (31%) showed no light perception (NLP). Drug susceptibility tests suggested that the carbapenems exhibited significant effects in the inflammatory reaction.

Conclusion

Endogenous endophthalmitis caused by liver abscess is a very serious condition, and the final visual outcome is poor. Timely surgical intervention combined with antibiotic treatment is essential, and the primary disease must be treated to control disease progression at the earliest.

Endogenous Klebsiella endophthalmitis as the presentation of both Klebsiella liver abscess and underlying anti-IFN-3 autoimmunity

This case study is one of the first ever reported examples of infection in a patient with anti-IFN-3 autoimmunity and demonstrates how overwhelming infection can sometimes present with visual symptoms. We report the case of a previously fit middle-aged patient presenting with painless loss of vision and loss of appetite. Examination showed choroidal abscess and a pan-uveitis, leading to admission for vitreous biopsy. Klebsiella pneumoniae was isolated both in the vitreous and in blood cultures. Subsequent investigation discovered a liver abscess which was treated with percutaneous drainage. Despite the administration of intravitreal antibiotics from the time of presentation, intravenous antibiotics and vitrectomy on the same day, the patient proceeded to need enucleation 19 days later, and now has only light perception in the remaining eye. The strong association between K. pneumoniae endophthalmitis and underlying liver abscess leads to a significant mortality rate. Early diagnosis is essential, with prompt aggressive treatment with antibiotics, but sadly the visual prognosis remains poor. In cases of suspected choroidal abscess, initiation of sepsis screen and immediate empirical treatment is vital to improve this prognosis. This patient had no significant past medical history, no known immunocompromise, was not diabetic and had no recent significant foreign travel. However, further immunological analysis demonstrated the presence of anti-IFN-3 antibodies, a hitherto under-reported potential cause of increased susceptibility to infection, and so cases of sepsis in previously healthy individuals should be considered for further immunology assessment.

Percutaneous fine-needle aspiration for pyogenic liver abscess (3-6 cm): a two-center retrospective study

BACKGROUND

The role of ultrasonography-guided percutaneous fine-needle aspiration (PNA) for pyogenic liver abscess (PLA) remains without consensus, especially in abscesses 3 to 6 cm in diameter. The objective of this study was to evaluate the comparative effectiveness and safety of PNA combined with antibiotics.

METHODS

This was a retrospective study of patients with PLA that were from 3 to 6 cm in diameter who treated at two medical centers in Shanghai, China, from January 2014 to March 2019. Patients were divided into groups treated by PNA plus antibiotics or antibiotics alone. Patients demographics and clinical data related diagnosis, antibiotic treatment, and patient outcomes were analyzed.

RESULTS

Out of a total of 94 PLA patients, 42 (44.7%) patients received PNA combined with antibiotics, and 52 (55.3%) received antibiotics alone. There were no complications related to PNA. In the PNA group, 13 (31.7%) patients with negative blood culture and 8 (19.5%) patients without blood culture were microbiologically confirmed via aspiration. The time for temperature normalization (P < 0.001) and the reduction rate of C-reactive protein within the first week (P = 0.031) were significantly lower in the PNA group. In the multivariate analysis, treatment with PNA was more likely to result in clinical improvement of PLA (odds ratio = 0.33, 95% confidence intervals (CI): 0.11-0.96, P = 0.043).

CONCLUSIONS

PNA combined with antibiotics appears to be a safe, effective, and promising treatment for PLA of 3-6 cm in size. Furthermore, the technique allows for direct microbial sample, which can improve the selection of antibiotics.

Effect of intravitreal ceftazidime injection on endogenous klebsiella pneumoniae endophthalmitis, a single center case series

To report long-term outcomes of intravitreal ceftazidime injection in patients with endogenous Klebsiella pneumoniae endophthalmitis (EKPE).This was a retrospective observational case study, including 7 eyes from 6 patients with EKPE. The medical records from January 2010 to December 2018 were reviewed.Diagnosis of EKPE was made based on the finding of endophthalmitis with concurrent systemic infection and positive blood culture result. All patients received tap and intravitreal ceftazidime injection base on the results of antibiotics sensitivity test. Visual acuity ranged from no light perception to 20/60 at initial visit, and the final visual acuity was 20/20. Two eyes underwent evisceration after intravitreal injection.Intravitreal ceftazidime injection showed favorable results in patients with EKPE.

Corneal Endotheliitis Associated with a Methicillin Resistant Pyogenic Liver Abscess

Endotheliitis is the inflammation of the corneal endothelium resulting in edema and subsequent loss of vision. Bacterial causes of corneal inflammation primarily of the epithelium with subsequent, secondary involvement of the endothelium have previously been described. Notably, however, there are no reports of isolated endotheliitis related to a bacterial pathogen. We report, for the first time, a case of corneal endotheliitis associated with a pyogenic liver abscess caused by methicillin resistant Staphylococcus aureus (MRSA). Treatment targeting the underlying source of infection led to visual recovery in our patient.

Endogenous Endophthalmitis Caused by Klebsiella pneumoniae: A Ten-Year Retrospective Study in Western China

OBJECTIVES

The aim of this study was to analyse the clinical features, microbiology results, management and outcomes of patients with endogenous endophthalmitis caused by Klebsiella pneumoniae in western China.

METHODS

A retrospective review of medical records of 10 eyes in 10 subjects diagnosed with endogenous K. pneumoniae endophthalmitis from January 2008 to December 2018 was undertaken.

RESULTS

The top 3 predisposing medical conditions included diabetes mellitus (50%), malignancy (20%) and cardiac stent implantation (10%). Extraocular infective foci were mainly found in the liver (40%), lungs (20%) and kidneys (10%). The positive culture rate was 85.71% (6/7) in vitreous samples, 83.33% (5/6) in blood samples and 100% (4/4) in body fluid samples. Only 20% of the patients, who had good initial visual acuity (VA) better than hand movement (HM), achieved a final VA better than 1.0 (log MAR). The mortality rate was 10%.

CONCLUSIONS

Though the prognosis of endogenous K. pneumoniae endophthalmitis is often poor, patients with an initial VA better than HM may have a good prognosis under comprehensive treatments, including vitrectomy, systemic sensitive antibiotic injection and drainage of the primary infection loci.