Thrombocytopenia in Klebsiella pneumoniae liver abscess: a retrospective study on its correlation with disease severity and potential causes

Objective

Thrombocytopenia is commonly associated with infectious diseases and serves as an indicator of disease severity. However, reports on its manifestation in conjunction with Klebsiella pneumoniae liver abscess (KPLA) are scarce. The present study sought to elucidate the correlation between thrombocytopenia and KPLA severity and delve into the etiological factors contributing to the incidence of thrombocytopenia.

Materials and methods

A retrospective analysis of the clinical data from patients with KPLA admitted between June 2012 and June 2023 was performed. Baseline characteristics, biochemical assessments, therapeutic interventions, complications, and clinical outcomes were compared between patients with and without thrombocytopenia. To investigate the potential etiologies underlying thrombocytopenia, the association between platelet count reduction and thrombophlebitis was examined, with a particular focus on platelet consumption. Furthermore, bone marrow aspiration results were evaluated to assess platelet production anomalies.

Results

A total of 361 KPLA patients were included in the study, among whom 60 (17%) had concurrent thrombocytopenia. Those in the thrombocytopenia group exhibited significantly higher rates of thrombophlebitis (p = 0.042), extrahepatic metastatic infection (p = 0.01), septic shock (p = 0.024), admissions to the intensive care unit (p = 0.002), and in-hospital mortality (p = 0.045). Multivariate analysis revealed that thrombocytopenia (odds ratio, 2.125; 95% confidence interval, 1.114-4.056; p = 0.022) was independently associated with thrombophlebitis. Among the thrombocytopenic patients, eight underwent bone marrow aspiration, and six (75%) had impaired medullar platelet production. After treatment, 88.6% of thrombocytopenic patients (n = 47) demonstrated recovery in their platelet counts with a median recovery time of five days (interquartile range, 3-6 days).

Conclusions

Thrombocytopenia in patients with KPLA is indicative of increased disease severity. The underlying etiologies for thrombocytopenia may include impaired platelet production within the bone marrow and augmented peripheral platelet consumption as evidenced by the presence of thrombophlebitis.

Evaluating the liver abscess microbiota of beef cattle during a reduction in tylosin supplementation shows differences according to abscess size and fraction

Liver abscesses (LA) resulting from bacterial infection in cattle pose a significant global challenge to the beef and dairy industries. Economic losses from liver discounts at slaughter and reduced animal performance drive the need for effective mitigation strategies. Tylosin phosphate supplementation is widely used to reduce LA occurrence, but concerns over antimicrobial overuse emphasize the urgency to explore alternative approaches. Understanding the microbial ecology of LA is crucial to this, and we hypothesized that a reduced timeframe of tylosin delivery would alter LA microbiomes. We conducted 16S rRNA sequencing to assess severe liver abscess bacteriomes in beef cattle supplemented with in-feed tylosin. Our findings revealed that shortening tylosin supplementation did not notably alter microbial communities. Additionally, our findings highlighted the significance of sample processing methods, showing differing communities in bulk purulent material and the capsule-adhered material. Fusobacterium or Bacteroides ASVs dominated LA, alongside probable opportunistic gut pathogens and other microbes. Moreover, we suggest that liver abscess size correlates with microbial community composition. These insights contribute to our understanding of factors impacting liver abscess microbial ecology and will be valuable in identifying antibiotic alternatives. They underscore the importance of exploring varied approaches to address LA while reducing reliance on in-feed antibiotics.

Prevalence of vascular thrombosis in patients with liver abscess

Thrombotic complications in liver abscess are less commonly identified in the literature. In this prospective observational study, vascular thrombosis was detected in 21.9% cases. However, there was no significant difference in outcome with or without vascular thrombosis, properly treated.

[COMMUNITY ACQUIRED KLEBSIELLA PNEUMONIAE LIVER ABSCESS - REPORT FROM ISRAEL]

Klebsiella pneumoniae is facultative anaerobic bacilli gram-negative bacteria. Klebsiella pneumoniae often causes urinary tract infections and sometimes causes community acquired pneumonia. During the past two decades, a distinct syndrome of Klebsiella pneumoniae with a pyogenic liver abscess was noted. The incidence is higher among patients with diabetes mellitus, and can cause serious complications, including bacteremia, meningitis, endophthalmitis and necrotizing fasciitis. The first cases were reported from Taiwan, but later, more cases emerged in other Asian countries. During recent years the incidence of Klebsiella pneumoniae liver abscess has increased globally, with cases also reported in Australia, New Zealand, West Europe and the United States. To the best of our knowledge, these are the first 2 cases described in Israel.

[COMMUNITY ACQUIRED KLEBSIELLA PNEUMONIAE LIVER ABSCESS - REPORT FROM ISRAEL]

Klebsiella pneumoniae is facultative anaerobic bacilli gram-negative bacteria. Klebsiella pneumoniae, often causes urinary tract infections and sometimes causes community acquired pneumonia. During the past two decades, a distinct syndrome of Klebsiella pneumoniae with a pyogenic liver abscess was noted. The incidence is higher among patients with diabetes mellitus, and can cause serious complications, including bacteremia, meningitis, endophthalmitis and necrotizing fasciitis. The first cases were reported from Taiwan, but later, more cases emerged in other Asian countries. During recent years the incidence of Klebsiella pneumoniae liver abscess has increased globally, with cases also reported in Australia, New Zealand, West Europe and the United States. To the best to our knowledge, these are the first 2 cases described in Israel.

Meta-analysis of the effects of essential oil as an alternative to monensin in diets for beef cattle

Additives used to improve feed efficiency of beef cattle on high-grain diets requires products that not only increase animal performance but also provide food safety for consumers. Since phytogenic additives such as essential oils (EO) are the main substitutes for monensin in the diet of cattle fed high-grain diets, this study aimed to evaluate, through meta-analysis, the effects of EO as an alternative to monensin in diets for beef cattle on feed intake, performance, carcass characteristics and ruminal fermentative parameters. Ten peer-reviewed publications with 27 treatment means were included in the data set. These effects were evaluated using random-effect models to examine the weighted mean differences (WMD) between EO treatment and control treatment (diets with monensin). Heterogeneity was explored by meta-regression and subgroup analysis. The substitution of EO for monensin did not affect methane production, ruminal pH values, average daily gain, feed efficiency or carcass weight. However, carcass dressing percentage (WMD = 0.38%; P = 0.03), ribeye area (WMD = 0.82 cm²; P < 0.0001) and subcutaneous fat thickness (WMD = 0.56 mm; P < 0.0001) values increased. Although the use of EO instead of monensin had no influence on the performance of beef cattle fed high-grain diets, the prevalence of hepatic abscesses increased 84.9% and the replacement of monensin by EO increased the risk ratio of hepatic abscess prevalence by 107%. Therefore, the use of EO in high-grain beef cattle diets was ineffective in protecting the liver against abscesses.

A study on causes of cattle liver condemnation at an abattoir in Omdurman area, Khartoum State, Sudan

BACKGROUND

Information obtained from abattoirs on the causes of liver condemnation is important in preventing the spread of diseases and for promoting food security. The current study reviews three years (2009 to 2011) postmortem inspection records of cattle slaughtered at an abattoir in Omdurman, Khartoum State, Sudan. The aim was to determine the prevalence of diseases and conditions that lead to liver condemnation.

RESULTS

From a total of 234,175 cattle slaughtered, 8,910 (3.8%) livers were condemned due to several diseases/conditions mainly fasciolosis, cysticercosis, necrosis, abscess, calcification, hemorrhages, liver cirrhosis, hydatidosis, and other miscellaneous causes. Collectively, fasciolosis was the leading cause of liver condemnation and was responsible for 51.6 % of total liver condemnations followed by necrosis (18.6%), and cysticercosis (13.5%).

CONCLUSIONS

Because of their zoonotic nature, the observed high frequency of some detected diseases/conditions is thought to pose a public health risk among consumers. This survey could be used as a regional baseline for future monitoring of control programmers against these liver diseases.

Case Report: First Molecular Diagnosis of Liver Abscesses Due to Fasciola hepatica Acute Infection Imported from Vietnam

We report a case of Fasciola hepatica liver abscesses in a 67-year-old female returning from a trip to Vietnam. She has been suffering from a fever, right abdominal pain for 4 days, and major eosinophilia. Radiologic investigations showed multiple hypodense confluent abscesses in the right lobe of the liver, complicated by occlusive thrombosis of the right branch of the portal vein. The serological investigation of helminth-elicited eosinophilia showed only a positive serology for F. hepatica. Despite repeated negative stool examinations for any intestinal pathogen, the diagnosis was established by the detection of F. hepatica DNA in stool and pus aspirate samples.

Diabetes and the Risk of Infection: A National Cohort Study

BACKGROUND

Several studies have shown that people with diabetes are vulnerable to infection. This study compared the risk of infection-related hospitalizations, intensive care unit (ICU) admission, and deaths between the person with diabetes and the general population in South Korea.

METHODS

We conducted a cohort study of 66,426 diabetes and 132,852 age-sex-region-matched non-diabetes controls from the general population using a sample of data from the National Health Insurance Service-National Sample Cohort. The cohort was followed up for 9 years. Infections were classified into 17 separate categories. We used Poisson regression, with adjustment for household income and other comorbidities, to estimate incidence rate ratios (IRRs) in order to compare of infection-related hospitalizations, ICU admissions, and deaths.

RESULTS

Compared to non-diabetes controls, diabetes group had a greater risk of almost all the types of infections considered, with the adjusted IRRs (aIRRs) for infection-related hospitalizations being the highest for hepatic abscess (aIRR, 10.17; 95% confidence interval [CI], 7.04 to 14.67), central nervous system (CNS) infections (aIRR, 8.72; 95% CI, 6.64 to 11.45), and skin and soft tissue infections other than cellulitis (SSTIs) (aIRR, 3.52; 95% CI, 3.20 to 3.88). Diabetes group also had a greater risk of ICU admission and death due to SSTIs (aIRR, 11.75; 95% CI, 7.32 to 18.86), CNS infections (aIRR, 5.25; 95% CI, 3.53 to 7.79), and bone and joint infections (aIRR, 4.78; 95% CI, 3.09 to 7.39).

CONCLUSION

In South Korea, people with diabetes has a considerably higher incidence of infection-related hospitalizations and deaths than the general population.

Investigation of tylosin in feed of feedlot cattle and effects on liver abscess prevalence, and fecal and soil microbiomes and resistomes1

Liver abscesses in feedlot cattle are detrimental to animal performance and economic return. Tylosin, a macrolide antibiotic, is used to reduce prevalence of liver abscesses, though there is variable efficacy among different groups of cattle. There is an increased importance in better understanding the etiology and pathogenesis of this condition because of growing concern over antibiotic resistance and increased scrutiny regarding use of antibiotics in food animal production. The objective of this study was to compare the microbiomes and antimicrobial resistance genes (resistomes) of feces of feedlot cattle administered or not administered tylosin and in their pen soil in 3 geographical regions with differing liver abscess prevalences. Cattle (total of 2,256) from 3 geographical regions were selected for inclusion based on dietary supplementation with tylosin (yes/no). Feces and pen soil samples were collected before harvest, and liver abscesses were identified at harvest. Shotgun and 16S rRNA amplicon sequencing were used to evaluate the soil and feces. Microbiome and resistome composition of feces (as compared by UniFrac distances and Euclidian distances, respectively) did not differ (P > 0.05) among tylosin or no tylosin-administered cattle. However, feedlot location was associated with differences (P ≤ 0.05) of resistomes and microbiomes. Using LASSO, a statistical model identified both fecal and soil microbial communities as predictive of liver abscess prevalence in pens. This model explained 75% of the variation in liver abscess prevalence, though a larger sample size would be needed to increase robustness of the model. These data suggest that tylosin exposure does not have a large impact on cattle resistomes or microbiomes, but instead, location of cattle production may be a stronger driver of both the resistome and microbiome composition of feces.

Hypervirulent Klebsiella pneumoniae in Cryptogenic Liver Abscesses, Paris, France

Liver abscesses containing hypervirulent Klebsiella pneumoniae have emerged during the past 2 decades, originally in Southeast Asia and then worldwide. We hypothesized that hypervirulent K. pneumoniae might also be emerging in France. In a retrospective, monocentric, cohort study, we analyzed characteristics and outcomes for 199 consecutive patients in Paris, France, with liver abscesses during 2010-2015. We focused on 31 patients with abscesses containing K. pneumoniae. This bacterium was present in most (14/27, 52%) cryptogenic liver abscesses. Cryptogenic K. pneumoniae abscesses were more frequently community-acquired (p<0.00001) and monomicrobial (p = 0.008), less likely to involve cancer patients (p<0.01), and relapsed less often (p<0.01) than did noncryptogenic K. pneumoniae liver abscesses. K. pneumoniae isolates from cryptogenic abscesses belonged to either the K1 or K2 serotypes and had more virulence factors than noncryptogenic K. pneumoniae isolates. Hypervirulent K. pneumoniae are emerging as the main pathogen isolated from cryptogenic liver abscesses in the study area.

Thiazolidinediones and reduced risk of incident bacterial abscess in adults with type 2 diabetes: A population-based cohort study

AIM

Previous research has suggested that peroxisome proliferator-activated receptor-gamma (PPAR-γ) may play an important role in immunomodulation. We aimed to examine the association between thiazolidinediones, PPAR-γ agonists and incidence of bacterial abscess among patients with type 2 diabetes.

MATERIALS AND METHODS

This retrospective cohort study between 2000 and 2010 included 46 986 propensity (PS)-matched patients diagnosed with type 2 diabetes. We compared the incidence of bacterial abscess, including liver and non-liver abscesses, between patients treated with metformin plus a thiazolidinedione (M + T, N = 7831) or metformin plus a sulfonylurea (M + S, N = 39 155). Data were retrieved from a population-based Taiwanese database. We applied Cox proportional hazard regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), comparing M + T and M + S after PS matching.

RESULTS

During a median follow-up of 4.5 years, the incidence rate of bacterial abscess was lower with M + T than with M + S treatment (1.89 vs 3.15 per 1000 person-years) in the PS-matched cohort. M + T was associated with a reduced risk of bacterial abscess (HRs after PS matching, 0.58; 95% CI, 0.42-0.80 for total bacterial abscess; 0.54; 95% CI, 0.28-1.07 for liver abscess; 0.59; 95% CI, 0.41-0.85 for non-liver abscess). Results did not change materially after accounting for unmeasured confounding factors using high-dimenional PS matching and differential censoring between regimen groups. Rosiglitazone and pioglitazone, in combination with metformin, produced similar reductions in risk of all abscess outcomes.

CONCLUSION

We found that M + T may provide a protective benefit in reducing the incidence of bacterial abscesses. These findings merit further investigation.

Hypervirulent Klebsiella pneumoniae, a 5-year study in a French ICU

PURPOSE

Hypervirulent Klebsiella pneumoniae (hvKp) has emerged as a leading cause of severe community-acquired pneumonia, liver abscess and disseminated infection in the Far East. Data regarding the incidence, clinical features and microbiological characteristics related to hvKp infections in the Western world are scarce.

METHODOLOGY

The incidence, clinical features and microbiological characteristics of hvKp infections were investigated through a 5-year survey conducted in a single French intensive care unit. K. pneumoniae strains were screened for hypermucoviscosity based on a string test. Multilocus sequence typing and multiplex PCR analysis targeting virulence genes were performed on string test-positive strains.

RESULTS

Over a 53-month period, a total of 59 infections due to K. pneumoniae were identified including 26 community-onset infections. Twelve hvKp infections were documented, accounting for 46.1 % of community-acquired K. pneumoniae. Community-acquired pneumonia (n=6), aspiration pneumonia (n=4) and liver abscess (n=2) represented initial sites and mode of infection. Compared to non-hvKp infections, patients with hvKp infections displayed higher rates of multi-organ failure (83.3 % vs 35.7 %; P=0.04), but mortality rates were not different (50 % vs 35 %; P=0.71). Strains K1/ST23 (n=5) and K2/ST86 (n=5) predominated. All hvKp strains displayed wild-type susceptibility.

CONCLUSION

hvKp represent a potentially underestimated cause of fatal infections in the Western world.

Liver abscess: contemporary presentation and management in a Western population

AIM

Historically, liver abscesses (LA) affected elderly, immunocompromised patients and were characterised by high morbidity and mortality, however there are no data pertaining to a New Zealand population with little information surrounding recent management trends.

METHODS

A retrospective review of demographic characteristics, clinical management and microbiological data on patients presenting with liver abscess between 2005-2014 was conducted.

RESULTS

Fifty-seven patients [37 males, median age 64 (range 15-87)] presented with LA and most patients were not comorbid. Ethnicity included European (47%), Chinese (16%) and Pacific Island (11%). Twenty-six patients had primary abscesses, 31 patients had secondary abscesses [biliary disease, appendicitis, diverticular disease]. Presenting symptoms were non-specific. Admission white cell count was raised in 50 (88%) of patients and 43 (75%) had a CRP≥200mg/L. All patients were investigated with CT scan with 34 LA located in the right lobe, 14 in the left and eight bi-lobar. Klebsiella pneumoniae was the commonest pathogen (26% of aspirates). Percutaneous drainage (PD) was used to treat 36 of 37 patients, 17 patients were treated with intravenous antibiotics alone and three patients required open drainage for loculated collections despite PD (n=1), intra-peritoneal rupture or sepsis (n=2). Thirteen patients were readmitted within 30 days for ongoing symptoms requiring intravenous antibiotics/further PD (9) or further investigations (4). The median PD duration was 10 days (range 3-53). Twenty-six patients required follow-up imaging over one month with 16 requiring follow-up over six weeks.

CONCLUSION

In a New Zealand setting, LA affect fit patients, and primary abscesses account for almost half of all presentation. PD is effective treatment in most LA although prolonged drainage and treatment with antibiotics may be necessary.

Management and outcome of hepatocellular adenoma with massive bleeding at presentation

AIM

To evaluate outcome of acute management and risk of rebleeding in patients with massive hemorrhage due to hepatocellular adenoma (HCA).

METHODS

This retrospective cohort study included all consecutive patients who presented to our hospital with massive hemorrhage (grade II or III) due to ruptured HCA and were admitted for observation and/or intervention between 1999-2016. The diagnosis of HCA was based on radiological findings from contrast-enhanced magnetic resonance imaging (MRI) or pathological findings from biopsy or resection of the HCA. Hemorrhage was diagnosed based on findings from computed tomography or MRI. Medical records were reviewed for demographic features, clinical presentation, tumor features, initial and subsequent management, short- and long-term complications and patient and lesion follow-up.

RESULTS

All patients were female (n = 23). Treatment in the acute phase consisted of embolization (n = 9, 39.1%), conservative therapy (n = 13, 56.5%), and other intervention (n = 1, 4.3%). Median hemoglobin level decreased significantly more on days 0-3 in the intervention group than in the patients initially treated conservatively (0.9 mmol/L vs 2.4 mmol/L respectively, P = 0.006). In total, 4 patients suffered severe short-term complications, which included hypovolemic shock, acute liver failure and abscess formation. After a median follow-up of 36 mo, tumor regression in non-surgically treated patients occurred with a median reduction of 76 mm down to 25 mm. Four patients underwent secondary (elective) treatment (i.e., tumor resection) to address HCA size of > 5 cm and/or desire for future pregnancy. One case of rebleeding was documented (4.3%). None of the patients experienced long-term complication (mean follow-up time: 36 mo).

CONCLUSION

With a 4.3% risk of rebleeding, secondary (elective) treatment of HCA after massive hemorrhage may only be considered in patients with persistent HCA > 5 cm.

Areas of research and clinical approaches to the study of liver abscess

AIM

To analyze the research activity on liver abscess (LA) and identify the main topic clusters in the area.

METHODS

We identified all documents using the medical subject heading “LA” indexed in the MEDLINE database between 2001 and 2015. We performed a descriptive bibliometric analysis, characterizing the evolution of scientific activity, the publication types of the documents, the document categories of clinical interest (case reports, clinical trials, evaluation studies, meta-analysis, observational studies, practice guidelines and validation studies) and the geographic distribution of the research. We also carried out an analysis of networks and research clusters in order to identify the main topic areas of research.

RESULTS

Our search yielded a total of 1278 documents, showing a stable scientific production over the study period and a marked multidisciplinary nature. The research was dominated by case reports (65.9% of the documents analyzed). In terms of geographic distribution, researchers from the United States led in the number of signatures (n = 229), followed by those from Taiwan (n = 185), India (n = 145), Japan (n = 144), South Korea (n = 100), and China (n = 84). With regard to amebic LA, the top-producing countries were India and Mexico (n = 69 each), followed by the United States (n = 29). In the case of pyogenic LA, Taiwanese researchers led scientific production (n = 71), followed by the United States (n = 39) and China (n = 29). The most active areas of research in the field are diagnosis via computerized tomography scan, differential diagnosis with regard to liver cancer, treatment with antimicrobial agents, and Klebsiella infections (including bacteremia).

CONCLUSION

Clinical case reports associated with diagnosis and treatment are the main topic of study, highlighting the importance of this document type in advancing knowledge.

Biliary fistula after liver resection: central role of intraoperative perihepatic drain

BACKGROUNDː Despite notable advances in surgical skills and technology, incidence of biliary fistula after hepatic resection remains an issue. Aim of this study was to assess the role of intraoperative perihepatic drain in diagnosis and treatment of this complication. METHODSː The study included 641 patients who underwent hepatic resection without hepaticojejunostomy between Jan-2003 and Jan-2016. Data were obtained from our single-institution perspective database. RESULTSː Biliary fistula occurred in 3.4% (22/641). Major hepatic resection (P<0.001), S4-involving resection (P=0.006), cholangiocarcinoma (P<0.001) and intraoperative blood losses >375 mL (P<0.001) were associated with biliary fistula. At multivariate analysis, among patients with effective intraoperative perihepatic drain ("D" group) (16/22) onset of biliary fistula (mean, 5.1 vs. 31.5 days, P=0.12) and healing time (mean, 26.5 vs. 82.3 days, P=0.033) were more favorable compared with biloma group (B). Moreover, conservative treatment was more effective in D group (75% of cases). B group developed increased morbidity in terms of jaundice (83.3% vs. 18.7%, P=0.005), abscess (66.7% vs. 6.2%, P=0.003) and a trend of prolonged hospital stay (mean, 25.7 vs. 19.2 days, P=0.51) and mortality (16.7% vs. 6.2%, P=0.449). Difference in biliary fistula severity rate according to ISGLS classification between the two groups was statistically significant (P=0.003). CONCLUSIONSː This study confirms that the wider is the resection the higher the risk for biliary fistula. A correct drainage of bile leakage is the crucial requisite for early healing, providing a milder postoperative course. In our experience, intraoperative perihepatic drain positioning plays a key-role, as well as postoperative patency monitoring.

Bacteraemia predictive factors among general medical inpatients: a retrospective cross-sectional survey in a Japanese university hospital

OBJECTIVES

The precise criteria for obtaining blood cultures have not been established; they depend on the physician's judgement. We examined clinical parameters to determine predictive factors of bacteraemia and the need for blood cultures among general medical inpatients.

DESIGN

A retrospective cross-sectional survey.

SETTING

A Japanese university hospital.

PARTICIPANTS

All general inpatients who had blood cultures taken from 1 January 2011 to 31 December 2012.

MAIN MEASURES

Clinical information at or just before blood culture sampling was extracted from medical charts. Factors potentially predictive of bacteraemia were analysed using Fisher's exact test, followed by multivariable logistic regression model analysis.

MAIN RESULTS

A total of 200 patients (male: female=119:81, 64.3±19.1 years old) comprised this study; 57 (28.5%) had positive blood culture results. Multivariable logistic regression analysis revealed that age >60 years (OR=2.75, 95% CI 1.23 to 6.48, p=0.015), female sex (OR=2.21, 95% CI 1.07 to 4.67, p=0.038), pulse rate >90 bpm (OR=5.18, 95% CI 2.25 to 12.48, p<0.001) and neutrophil percentage >80% (OR=3.61, 95% CI 1.71 to 8.00, p=0.001) were independent risk factors for positive blood culture results. The area under the receiver operating characteristic curve analysis of this model was 0.796.

CONCLUSIONS

Our results emphasise the importance of taking blood cultures if the pulse rate is >90 bpm, in elderly patients and in women, and for ordering a differential white cell count.

Recent trend of pylephlebitis in Taiwan: Klebsiella pneumoniae liver abscess as an emerging etiology

BACKGROUND AND AIMS

Pylephlebitis (septic thrombophlebitis of the portal venous system) is a rare complication of intra-abdominal infection. We aimed to investigate the recent trend of its etiology, clinical manifestation, and prognosis.

METHODS

We retrospectively studied the etiology, clinical manifestation, and outcome by reviewing the medical records of all imaging-confirmed pylephlebitis cases diagnosed during the period 2002-2011 in a university hospital in Taiwan. To identify the risk factors for pylephlebitis, we randomly selected 160 patients with intra-abdominal infections but without pylephlebitis as the comparison group.

RESULTS

We identified 35 cases of pylephlebitis. Most patients were men [29/35 (83 %)]. The median age of the patients was 57 years (range 35-90 years). Unspecified abdominal pain (18/35) and fever (10/35) were the most common clinical manifestations. Klebsiella pneumoniae liver abscess (7/35) and cholangitis (7/35) were the most common etiologies. Liver abscess was a risk factor for pylephlebitis (13/35 vs. 27/160, P = 0.01). With antibiotic therapy, there was no in-hospital mortality, but pylephlebitis was still associated with an excess hospital stay (22.2 ± 17.6 vs. 9.8 ± 7.1 days, P < 0.001).

CONCLUSIONS

Our study results suggested a different pattern of pylephlebitis from previous Western literature. K. pneumoniae liver abscess (7/35) is an emerging etiology of pylephlebitis in Taiwan.

Klebsiella pneumoniae liver abscess: a new invasive syndrome

Klebsiella pneumoniae is a well known human nosocomial pathogen. Most community-acquired K pneumoniae infections cause pneumonia or urinary tract infections. During the past two decades, however, a distinct invasive syndrome that causes liver abscesses has been increasingly reported in Asia, and this syndrome is emerging as a global disease. In this Review, we summarise the clinical presentation and management as well the microbiological aspects of this invasive disease. Diabetes mellitus and two specific capsular types in the bacterium predispose a patient to the development of liver abscesses and the following metastatic complications: bacteraemia, meningitis, endophthalmitis, and necrotising fasciitis. For patients with this invasive syndrome, appropriate antimicrobial treatment combined with percutaneous drainage of liver abscesses increases their chances of survival. Rapid detection of the hypervirulent strain that causes this syndrome allows earlier diagnosis and treatment, thus minimising the occurrence of sequelae and improving clinical outcomes.

[Meticilin resistant Staphylococcus aureus and liver abscess: a retrospective analysis of 117 patients]

INTRODUCTION

Liver abscesses are a clinical entity difficult to diagnose and treat; therefore, a high index of suspicion is usually important. The majority of pyogenic liver abscesses are polymicrobial, with enteric and anaerobic bacteria being the most common. Staphylococcus aureus are found in around 7% of the liver abscesses, as reviewed in literature. This infection usually results from hematogenous dissemination of bacteria that's infecting some other organ. There are no published series on this matter, only case-reports.

OBJECTIVES AND METHODS

In order to investigate the physiopathology, diagnosis and natural history of liver abscesses, namely those caused by methicillin-resistant Staphylococcus aureus (MRSA), we conducted a retrospective review by studying the clinical files of the patients diagnosed with liver abscess/portal pyemia between January of 2004 and December of 2009, with a total of 117 patients.

RESULTS

Fever and abdominal pain were the most common symptoms. Nearly all patients had a CT scan for diagnosis. Only 81.2% of patients had microbiological products collected. The most common pathogen isolated was Escherichia coli. MRSA was isolated in 7.6% of abscesses. Percutaneous drainage combined with antibiotic therapy was the most frequent treatment used. All MRSA isolated were susceptible to trimethoprim-sulfamethoxazole and vancomycin. The underlying conditions most frequently found were biliary diseases, followed by recent abdominal surgery, which in turn was the most frequent predisponent condition in MRSA liver abscesses. The total mortality rate was 17.9%. One patient died in the group of abscesses caused by MRSA.

CONCLUSION

MRSA is an important pathogen in hospital-acquired infections and intraabdominal infections are no exception. We find the association with post abdominal surgery very important. These findings have remarkable implications in therapeutics, prognosis and investigation.

[Ultrasonographic features of liver abscess based on a 58-case series in Cameroon]

Amoebic abscess is the most frequent type of liver abscess in tropical areas, including in immunocompromised patients. Abscesses affect the right lobe in 74% of cases and are solitary in more than 80%. The ultrasonographic features of liver abscess vary according to stage, viscosity of liquid contents, amount of debris inside and presence of gas bubbles. Multiple small abcesses are mainly associated with pyogenic abscess and are promoted by HIV infection.

Liver abscesses in feedlot cattle

Liver abscesses in feedlot cattle result from aggressive grain-feeding programs and are influenced by a number of dietary and management factors. They have a major economic impact on the feedlot industry because of liver condemnation and reduced animal performance and carcass yield. Ruminal lesions resulting from acidosis usually are accepted as the predisposing factors. Generally, control of liver abscesses in feedlot cattle has depended on the use of tylosin, which reduces abscess incidence by 40% to 70%. However, new methods and products for liver abscess control are needed. Corn milling by-products that are less fermentable may aide in the quest for cattle production techniques that lead to lower usage of antimicrobials. A vaccine is also commercially available.

Capsular serotype K1 or K2, rather than magA and rmpA, is a major virulence determinant for Klebsiella pneumoniae liver abscess in Singapore and Taiwan

Capsular serotypes, magA, and rmpA have been documented in high prevalence for Klebsiella pneumoniae liver abscess. To investigate the regional difference and the correlation of capsular serotype, magA, and rmpA with virulence, 73 isolates were collected in Singapore and Taiwan. Capsular serotypes were determined by countercurrent immunoelectrophoresis, the presence of magA and rmpA was determined by PCR, and virulence was determined by phagocytosis and mouse inoculation. Isolates from Singapore were similar to those from Taiwan in genomic heterogeneity, prevalence of serotype, and the presence of magA and rmpA. The most common serotype was K1 (34/73; 46.6%), followed by K2 (15/73; 20.5%). magA was restricted to serotype K1. All K1 or K2 isolates and 66.7% (16/24) of isolates that were neither serotype K1 nor serotype K2 (non-K1/K2) carried rmpA. Serotype K1 or K2 isolates demonstrated significantly more phagocytic resistance and virulence than did rmpA-positive and -negative groups of non-K1/K2 isolates. In the non-K1/K2 group, the virulence profiles of rmpA-positive strains from Taiwan and Singapore were different by phagocytosis assay and in the mouse model, indicating that factors other than rmpA contributed to virulence. The characteristics of K. pneumoniae liver abscess in Singapore and Taiwan are similar. Capsular serotype K1 or K2 plays a more important role than magA and rmpA in determining virulence in K. pneumoniae liver abscess.

Emerging invasive liver abscess caused by K1 serotype Klebsiella pneumoniae in Korea

OBJECTIVES

The high incidence of invasive liver abscess caused by Klebsiella pneumoniae in Taiwan, contrasted with the rareness of this disease in Western countries, has aroused special interest. There have been few detailed reports from other Asian countries. To investigate a current epidemiology of K. pneumoniae liver abscess in Korea and to determine K serotype distribution in K. pneumoniae strains causing liver abscess, we performed a nationwide prospective study.

METHODS

Community-acquired, culture-proven liver abscess cases were enrolled between 2004 and 2005. Etiologies and clinical features were analyzed. K. pneumoniae isolates were serotyped according to K antigen. Meta-analysis was done to determine the time trend of the etiologies of liver abscess in Korea.

RESULTS

Out of 371 cases collected prospectively, 290 (78.2%) were caused by K. pneumoniae. Most K. pneumoniae liver abscesses were monomicrobial. Diabetes mellitus was the most common underlying disease (39.9%). Distant metastatic infections were frequently observed (8.7%). magA PCR revealed that 95 (59.4%) out of 160 K. pneumoniae isolates belonged to the K1 serotype.

CONCLUSIONS

Our study indicates that K. pneumoniae has emerged as a major etiologic agent of liver abscess in Korea, and these emerging infections seem to be attributable to invasive K. pneumoniae strains with capsular K1 serotype.

Liver abscesses in children: a single center experience in the developed world

OBJECTIVES

The aim of this study was to investigate the clinical and radiologic features, predisposing risk factors, and complications of children with pyogenic liver abscess (PLA) referred to a tertiary pediatric hepatology center.

METHODS

We analyzed our database of all children referred to our unit over a 10 year period and performed a case note review of all patients with a radiologically proven PLA.

RESULTS

PLA was diagnosed in 15 children (7 boys), 0.5% of all referrals. They presented at a median age of 10 years (range 2 months-15 years). In three children (2 boys), PLA was the first manifestation of chronic granulomatous disease. Among the others, five had radiologic evidence of other intra-abdominal pathology (1 with subsequently proven appendicitis), and four developed portal vein thrombosis with portal hypertension. The commonest isolated pathogen was Staphylococcus aureus. Combined treatment with guided aspiration and prolonged intravenous antibiotics was successful in all patients.

CONCLUSION

PLA is a rare diagnosis in children in the developed world. It may be caused by primary neutrophil disorders even in the absence of a previous history of infection. Co-existent appendicitis, intra-abdominal sepsis, and ascending pylephlebitis must be sought because these children are at risk of developing portal vein obstruction and portal hypertension. Prolonged intravenous antibiotic treatment guided by microbiologic sensitivities is highly effective.

Liver abscess caused byEdwardsiella tardabiogroup 1 and identification of its epidemiological triad by ribotyping

Two clinical isolates and an environmental isolate of Edwardsiella tarda biogroup 1 (ETB1), recovered from liver pus, the stool specimen and from the pond water of the village of the patient, diagnosed to have liver abscess, were found to be identical by protein fingerprinting and ribotyping. It can be construed that the pond water served as the source of infection. The epidemiological triad of the agent (ETB1), host (the patient) and environment (pond water) was thus established. This is the first report in which the triad for extraintestinal Edwardsiellosis caused by ETB1 has been identified. This also constitutes the first report of typing of ETB1 strains by SDS-PAGE and ribotyping.

Efficacy of vaccination against Fusobacterium necrophorum infection for control of liver abscesses and footrot in feedlot cattle in western Canada

A randomized and blinded field trial was carried out to evaluate the efficacy of a Fusobacterium necrophorum bacterin for control of liver abscesses and footrot under commercial feedlot conditions in western Canada. Half of the vaccinated and half of the unvaccinated control animals had ad libitum access to a forage-based (ALF) growing diet. The other half of each group was limit-fed a grain-based (LFG) growing diet. The overall prevalence of A and A+ liver abscesses in this trial was 16.7%. A strong association was found between diet group and presence of A or A+ liver abscessation at slaughter. Diet group modified the effect of vaccination on the prevalence of liver abscesses at slaughter, and on the incidence of footrot during the feeding period. The odds that a vaccinated animal in the ALF group would have an A or A+ liver abscess at slaughter were less than 1/3 the odds that an unvaccinated animal in the same diet group would have an A or A+ liver abscess at slaughter (OR = 0.27, [95% CI: 0.07 to 1.02], P = 0.05). The overall incidence of footrot in this trial was 6.5%. The odds that a vaccinated animal in the ALF group would be treated for footrot were less than 1/5 the odds that an unvaccinated animal in the same group would be treated for foot-rot (OR = 0.18, [95% CI: 0.04 to 0.82], P = 0.03). Within the LFG group there were no differences between vaccinated and unvaccinated animals in the odds of an animal being treated for footrot, or in the odds of having an A or A+ liver abscess score at slaughter. This trial suggests that vaccination against F. necrophorum infection may have applications to decrease the prevalence of severe liver abscesses at slaughter and decrease footrot treatments in certain diet situations.

Fulminant infection with emphysematous changes in the biliary tract and air-filled liver abscesses

Gas-producing infections are related to anaerobic bacteria and usually associated with immunosuppressive pathologies such as diabetes and have a fulminating course. We present the clinical course of a patient with diabetes whose infection progressed rapidly and ended in her dramatic death in a short period; surgical therapy was impossible, and the disease behaved similarly to type I emphysematous pyelonephritis.

Neonatal hepatic abscess in preterm infants:a rare entity?

INTRODUCTION AND OBJECTIVE

Neonatal pyogenic hepatic abscess in preterm infants is a rare entity. We present 6 cases of neonatal liver abscesses diagnosed in our hospital as well as an approach that will facilitate the early diagnosis and management of neonatal pyogenic liver abscess based on our case series and review of the literature.

MATERIALS AND METHODS

Retrospective review of case records of all 6 patients diagnosed with neonatal liver abscess from January 2000 to December 2002 in KK Women's and Children's Hospital, Singapore.

RESULTS

All neonates were premature with gestational ages between 24 and 34 weeks. Persistence of positive blood culture despite appropriate antibiotic treatment in 67% of the cases prompted use of hepatobiliary ultrasounds to detect liver abscess. Surgical drainage of liver abscess was performed in 33% of the cases, with the remainder treated conservatively with appropriate intravenous antibiotics. Half of the infants recovered with resolution of their liver abscess on serial hepatobiliary ultrasound. The other half died of fulminant sepsis.

CONCLUSIONS

Neonatal pyogenic liver abscess, though rare, is associated with good outcome if diagnosed promptly and appropriate treatment instituted. In a preterm infant with sepsis, a high index of suspicion is required if there is persistence of positive blood culture despite appropriate antibiotic treatment, and hepatobiliary ultrasound should be done to detect and monitor neonatal liver abscess.

Liver abscess after percutaneous radiofrequency ablation for hepatocellular carcinomas: frequency and risk factors

OBJECTIVE

The purpose of this study was to clarify the frequency and risk factors of liver abscess formation after percutaneous radiofrequency ablation in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Over a 4-year period, 603 patients with 831 hepatocellular carcinomas measuring 5 cm or less in maximum diameter who underwent a total of 751 percutaneous radiofrequency ablation procedures were enrolled in this study. We retrospectively reviewed the medical records and analyzed the overall frequency of liver abscess, risk factors for abscess, and clinical features of the patients. The relationships between liver abscess and potential risk factors were analyzed using either generalized estimating equations or multiple logistic regression analysis.

RESULTS

Liver abscess developed in 14 tumors of 13 patients after 13 (13/751 [1.7%]) ablation procedures. Generalized estimating equations and multiple logistic regression analysis of various potential risk factors revealed that preexisting biliary abnormality prone to ascending biliary infection (p = 0.0088), tumor with retention of iodized oil from previous transcatheter arterial chemoembolization (p = 0.040), and treatment with an internally cooled electrode system (p = 0.016) were associated with a significant risk of liver abscess formation. No patient died of liver abscess, and all successfully recovered from liver abscess with parenteral antibiotics and percutaneous clearance of pus.

CONCLUSION

Although liver abscess formation was infrequent in patients who underwent percutaneous radiofrequency ablation for hepatocellular carcinoma, the patients with significant risk factors-preexisting biliary abnormality prone to ascending biliary infection, tumor with retention of iodized oil, and treatment with an internally cooled electrode system-for liver abscess formation should be closely monitored after treatment.

Reappraisal of percutaneous transhepatic cholangioscopic lithotomy for primary hepatolithiasis

BACKGROUND

A review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery.

METHODS

A retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome.

RESULTS

Complete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p < 0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p < 0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p < 0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p > 0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p > 0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p < 0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p < 0.01).

CONCLUSIONS

The findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.

Clinical and laboratory aspects of chronic granulomatous disease in description of eighteen patients

To describe the epidemiological, clinical, laboratory, and evolution characteristics of 18 patients with chronic granulomatous disease (CGD). In this retrospective study, clinical, laboratory, and epidemiological data were obtained from the medical records of all patients with CGD seen at the Allergy and Immunology Unit of the Pediatrics Department (School of Medicine, University of Sao Paulo) from January 1979 to December 2001. Medical history and physical examination data, personal and family history, presence of consanguinity, weight and height data, presence of hepatosplenomegaly, adenomegaly, or other relevant alterations at the time of admission were obtained for all patients. We reviewed 18 patients (male:female, 8:1) with a median duration of symptoms of 1.25 months and with a median time since diagnosis of 13 months. A family history of death as a result of infection was reported by three patients and five other patients had a common relative with CGD who was included in the series. The clinical manifestations observed were: failure to thrive, adenomegaly, hepatosplenomegaly, pneumonia, and abscesses. Relevant laboratory data were hypergammaglobulinemia and nitroblue tetrazolium reduction test of 0% in 14 patients. Seven patients received IFN-gamma and 11 sulfamethoxazole-trimethoprim. Six patients died of suppurative pulmonary infections. Age at the onset of symptoms was early, although diagnosis was late in some patients. Pulmonary involvement was the most prevalent clinical manifestation in the different phases of the disease and the major cause of death. Hypergammaglobulinemia, anemia, and leukocytosis were relevant laboratory data.

A 10-year comparison of endogenous endophthalmitis outcomes: an east Asian experience with Klebsiella pneumoniae infection

PURPOSE

To evaluate the infection sources and causative organisms in cases of endogenous endophthalmitis and review the outcomes for patients with Klebsiella pneumoniae infection during a 10-year period.

METHODS

All cases of endogenous endophthalmitis treated at one Taiwanese hospital from July 1992 to June 2002 were retrospectively reviewed (n = 74; 86 eyes). The study was divided into two 5-year periods, with patients stratified into Group F or Group L according to onset date within the first or last of these periods, respectively. The outcomes of cases of K. pneumoniae infection in Group L (21 eyes) and Group F (32 eyes) were compared.

RESULTS

The major source of infection (liver abscess) and the causative organism (K. pneumoniae) did not change throughout the 10-year review period; however, outcomes for Group L appeared superior. The interval from onset of ocular symptoms to ophthalmic consultation was shorter for Group L; however, a statistically significant difference was not demonstrated by between-group comparison. Patients with good final vision typically had good initial vision in cases of K. pneumoniae infection.

CONCLUSION

The authors' experience with endogenous endophthalmitis has confirmed the findings of analogous East Asian studies, with liver abscess as the major source of infection and K. pneumoniae as the causative organism. Superior outcome may be achieved with more comprehensive and collaborative management, ideally through the combined efforts of multiple medical subspecialties.

Hepatic abscesses in cats: 14 cases (1985-2002)

In this retrospective study, we describe 14 cats diagnosed with hepatic abscesses. The objective of the study was to report the clinical signs, physical examination findings, clinicopathologic findings, and outcomes in affected cats. These findings were then compared with those previously reported in dogs and humans. Clinical signs were vague and included anorexia, lethargy, and weight loss. Only 23% of cats had fever, whereas 31% were hypothermic. Increases in serum activities of alanine aminotransferase and alkaline phosphatase were found in 45 and 18%, respectively, of the 11 cats that had laboratory work performed. Abdominal ultrasound examinations were performed in 7 cats, and abnormalities were found in 71% of them. Four cats had solitary abscesses, all of which were located in the right liver lobes. The other 10 cats had multifocal small abscesses or microabscesses, and all of these cats had clinical signs suggestive of sepsis. Cytologic evaluation of samples obtained by abdominocentesis indicated septic inflammation in 67% of cats in which peritoneal fluid was analyzed. Hepatic abscess cultures yielded polymicrobial growth in 66% of the cats: Escherichia coli was the most commonly cultured organism. Overall mortality rate was 79%. All survivors underwent exploratory laparotomy for partial hepatectomy to resect the abscess followed by medical management. Hepatic abscesses should be considered in cats with signs consistent with sepsis. More routine use of ultrasonography may aid in earlier diagnosis of hepatic abscesses, potentially improving prognosis and outcome.

Liver abscess in the tropics: an experience from Nepal

Thirty-six consecutive cases of liver abscess seen at the BP Koirala Institute of Health Sciences Hospital, Dharan, Nepal, from 1995 to 1998, were reviewed. Twenty-one cases were male and 15 female, with a mean age of 42 years. Twenty-four cases (66.7%) were amebic, 7 (19.4%) pyogenic, 3 (8.3%) indeterminate and 2 (5.5%) tuberculous. The most frequent clinical features included fever (88%), leukocytosis (66.7%), abnormal level of serum albumin (44.4%) and alkaline phosphatase (38.9%). The liver abscess was single in 61.1%, multiple in 27.8%, and in 66.7% of cases the abscess was present in the right lobe of the liver. Ultrasonography was diagnostic in all cases. A positive culture of the abscess was obtained in 7 cases (19.4%). The most frequent bacteria found were Klebsiella pneumoniae (4;11.1%), followed by Escherichia coli (3;8.3%). Two cases were due to Mycobacterium tuberculosis and none had malignancy. Percutaneous drainage was performed in 27 patients (75%). Mortality attributable to the abscess was 5.5%. We found percutaneous needle aspiration of liver abscess helpful in confirming diagnosis, as it provides a better bacteriological culture yield, gives a good outcome, and may uncover clinically unsuspected conditions like malignancy and tuberculosis. These two conditions should certainly be considered possible causes in our part of the world when an abscess fails to respond to standard treatment. In developing countries like Nepal, the clinical presentation of liver abscess has not varied over time. At present, rapid diagnosis and image-guided percutaneous drainage offer a better prognosis for liver abscess. We also recommend routine cytological examination of aspirated abscess materials, as well as stains and cultures for acid-fast bacilli.

Cholangitis and Liver Abscess after Percutaneous Ablation Therapy for Liver Tumors: Incidence and Risk Factors

PURPOSE

To determine the risk factors of cholangitis and liver abscess occurring after percutaneous ablation therapy for liver tumors.

MATERIALS AND METHODS

Between October 1995 and September 2002, 358 patients with 455 liver tumors underwent a total of 683 ablation procedures, such as percutaneous ethanol injection (PEI), percutaneous microwave coagulation (PMC), and radiofrequency (RF) ablation therapy. With a retrospective review of medical records, the rates and outcomes of cholangitis and/or liver abscess occurring after ablation therapy were evaluated. The relationship between cholangitis and/or liver abscess and multiple variables (age, disease, Child-Pugh class, size of nodules, multiplicity of nodules, history of transcatheter arterial embolization, presence of bilioenteric anastomosis, and lack of prophylactic antibiotics administration) were statistically analyzed.

RESULTS

Cholangitis and/or liver abscess occurred in 10 sessions (1.5%) in 10 patients: six sessions after PEI, three sessions after PMC, and one session after RF ablation. Both cholangitis and liver abscess were noted in seven sessions, cholangitis was noted in two, and liver abscess was noted in one. Six patients recovered, but two developed recurrent cholangitis and liver abscess, one developed lung abscess complicated with liver abscess, and one died of septic shock associated with cholangitis. On stepwise regression analysis, bilioenteric anastomosis was the sole significant predictor of cholangitis and/or liver abscess formation (P <.001; odds ratio = 36.4; 95% CI = 9.67-136.9).

CONCLUSION

Bilioenteric anastomosis strongly correlated with the development of cholangitis and/or liver abscess after percutaneous ablation therapy. Close posttreatment attention should be paid to this subgroup of patients.

[Liver abscess: a practical approach]

The management of a liver abscess suspected on the basis of clinical and radiological findings is radically different depending on its amoebic or pyogenic etiology. Medical management is usually enough to treat amoebic abscess, the prognosis of which is excellent while percutaneous aspiration puncture, drainage and antibiotics is the rule in pyogenic abscess, the prognosis of which depends on the quickness of diagnosis and risk factors associated. This article first relates a case of liver abscess we had in our service and then propose, on the basis of a literature review, a synthesis of the different characteristics, diagnostic and therapeutic approaches and follow-up of amoebic and pyogenic liver abscesses.

Liver abscess formation after transarterial chemoembolization for malignant hepatic tumor

BACKGROUND/AIMS

To study and review the clinical manifestations, microbiology, comorbidity, and diagnosis of liver abscess after transarterial chemoembolization for malignant hepatic tumor.

METHODOLOGY

We retrospectively reviewed 1374 patients who underwent 2581 transarterial chemoembolization procedures due to malignant hepatic tumors over an 8-year period.

RESULTS

7 patients had liver abscess after transarterial chemoembolization. The incidence was 0.27% (7/2581). Hepatocellular carcinoma was diagnosed in all 7 patients, whose liver function was classified as stage A by the Child-Pugh criteria. The clinical manifestations were intermittent fever, abdominal pain, and leukocystosis. All the patients had hyperechoic spots with reverberative shadows on sonograms or low attenuation areas with different Hounsfield units on computed tomography scan, which expressed the 100% incidence (7 of 7) of gas-forming abscesses. Percutaneous drainage or aspiration was done in 6 patients. One received laparotomy with local debridement due to suspicious organ rupture. The pus culture showed Gram-negative bacteria in all patients. Blood cultures were positive in only 3 of 7 patients (43%). No patients died of liver abscess after aspiration, drainage, or debridement of abscess combined with parenteral antibiotic treatment. Biliary tract diseases, found in 4 patients, were the most common comorbidity.

CONCLUSIONS

Liver abscess after transarterial chemoembolization is a very rare complication, which usually develops in patients with biliary tract disease. Gram-negative bacteria are the main pathogens. The incidence of gas formation is higher after transarterial chemoembolization than in the general population. However, the prognosis is good after adequate clearance of pus and antibiotic treatment.

Extended-spectrum cephalosporin compared to cefazolin for treatment of Klebsiella pneumoniae-caused liver abscess

From January 1995 to May 2000, a total of 107 adults with liver abscess due to Klebsiella pneumoniae admitted at a large medical center in northern Taiwan were reviewed. Patients were considered to have received cefazolin or an extended-spectrum cephalosporin if they received at least 3 days of that antibiotic within the first 5 days of hospitalization. Fifty-nine (55.1%) patients received cefazolin, and 48 (44.9%) patients received an extended-spectrum cephalosporin. The demographic data, clinical features, severities of illness, and rates of early drainage for the two groups were comparable. However, the rates of developing complications for the two groups were significantly different (37.3 versus 6.3%, respectively; P < 0.001). Furthermore, six independent factors preventing severe complications following liver abscess due to K. pneumoniae were identified: normal platelet count, alkaline phosphatase less than 300 U/liter, no gas formation in the abscess, APACHE III score less than 40, use of an extended-spectrum cephalosporin, and early drainage. In conclusion, cefazolin therapy may be suboptimal for patients with liver abscess due to K. pneumoniae despite active in vitro susceptibility. Use of an extended-spectrum cephalosporin and early drainage for patients with liver abscess due to K. pneumoniae are suggested.