Figure - available from: Journal of Clinical and Translational Hepatology
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Ultrasound (US) A. US demonstrates a hypoechoic abscess with heterogeneous echogenicity centrally consistent with septations and internal debris (blue arrow). B. Color Doppler US demonstrates peripheral hypervascularity surrounding the abscess cavity.
Source publication
Hepatic abscess (HA) remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed...
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Citations
... Klebsiella pneumoniae and Escherichia coli are the most common etiological agents of PLAs in immunocompromised patients [2,3]. Liver transplantation and diabetes mellitus (DM) are two known risk factors for the development of PLA [1,4]. K. pneumoniae readily colonizes the intestine and can cross the intestinal barrier to enter the liver via the portal vein system and cause PLA in healthy and immunocompromised individuals [1,2]. ...
Background
Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are a major public health problem, necessitating the administration of polymyxin E (colistin) as a last-line antibiotic. Meanwhile, the mortality rate associated with colistin-resistant K. pneumoniae infections is seriously increasing. On the other hand, importance of administration of carbapenems in promoting colistin resistance in K. pneumoniae is unknown.
Case presentation
We report a case of K. pneumoniae-related pyogenic liver abscess in which susceptible K. pneumoniae transformed into carbapenem- and colistin-resistant K. pneumoniae during treatment with imipenem. The case of pyogenic liver abscess was a 50-year-old man with diabetes and liver transplant who was admitted to Abu Ali Sina Hospital in Shiraz. The K. pneumoniae isolate responsible for community-acquired pyogenic liver abscess was isolated and identified. The K. pneumoniae isolate was sensitive to all tested antibiotics except ampicillin in the antimicrobial susceptibility test and was identified as a non-K1/K2 classical K. pneumoniae (cKp) strain. Multilocus sequence typing (MLST) identified the isolate as sequence type 54 (ST54). Based on the patient’s request, he was discharged to continue treatment at another center. After two months, he was readmitted due to fever and progressive constitutional symptoms. During treatment with imipenem, the strain acquired blaOXA−48 and showed resistance to carbapenems and was identified as a multidrug resistant (MDR) strain. The minimum inhibitory concentration (MIC) test for colistin was performed by broth microdilution method and the strain was sensitive to colistin (MIC < 2 µg/mL). Meanwhile, on blood agar, the colonies had a sticky consistency and adhered to the culture medium (sticky mucoviscous colonies). Quantitative real-time PCR and biofilm formation assay revealed that the CRKP strain increased capsule wzi gene expression and produced slime in response to imipenem. Finally, K. pneumoniae-related pyogenic liver abscess with resistance to a wide range of antibiotics, including the last-line antibiotics colistin and tigecycline, led to sepsis and death.
Conclusions
Based on this information, can we have a theoretical hypothesis that imipenem is a promoter of resistance to carbapenems and colistin in K. pneumoniae? This needs more attention.
... Bacterial infections are the most common with Escherichia Coli being the most common organism in the western population and Klebsiella Pneumonia being the emerging organism in Asia. The risk factors for developing liver abscess include advanced age, male gender, immune compromised state, diabetes mellitus and liver cirrhosis [1,2]. ...
Liver abscess can be divided into pyogenic and amoebic liver abscess. The common organisms that cause pyogenic liver abscess include Escherichia Coli, with amoebic liver abscess being caused by Entamoeba histolytica. The diagnosis is made by ultrasound, computerized tomography, and magnetic resonance imaging of the liver. The treatment can be divided into medical therapy which involves percutaneous drainage and intravenous antibiotics, and surgical therapy which includes surgical drainage either by open or laparoscopic surgery. Surgical drainage is indicated for patients who have failed medical therapy. We have conducted this review article to look at the current management of liver abscess with regards to the role of percutaneous drainage and surgical drainage.
... The most common source of pyogenic liver abscesses is biliary tract infection due to obstruction and inflammatory conditions [3]. Other less common routes of hepatic invasion include the spread of bacteria from distant foci (apendicitis, diverticulitis, etc.) to the liver parenchyma through the portal circulation [4] or via the hepatic artery in the setting of bacteremia [5]. ...
... More rarely, a hepatic abscess may result from penetrating (infected liver biopsies) or blunt (biliary stenting in the case of malignancy) hepatic trauma [3], from miscellaneous causes such as extension from empyema of the gallbladder [6], from a subphrenic abscess or due to cholecystogastrocolonic fistula [7]. Known risk factors for liver abscess include age > 65 years, male sex, diabetes mellitus, malignancy, alcoholism, cirrhosis and liver transplantation [8]. ...
Background
The most common source of pyogenic liver abscess is biliary tract infection. Other less common routes include the spread of bacteria from distant foci. However, direct extension of a perinephric infection focus to the liver is extremely rare.
Case report
The patient was a non-diabetic, immunocompetent, 29-year-old woman of mixed race ancestry with a history of recurrent urinary tract infections who was referred to our hospital because of an ultrasound-detected liver abscess. She was initially treated with metronidazole for 20 days at the referring institution for suspected amebic abscess without improvement. On admission to our center, she was febrile and complained of a dull right upper quadrant pain. A POCUS ultrasound suggested a pyogenic abscess, probably from a staghorn calculus infection. She received meroperem and amikacin for 22 and 10 days, respectively. Repeat hemocultures showed no growth, but urine cultures were positive for Proteus sp. Complete remission of clinical and imaging findings was observed under antibiotics. The patient was referred to the urology outpatient clinic to discuss the option of radical nephrectomy.
Conclusion
This case underlines the high morbidity of staghorn calculi.
... (8) En nuestro estudio los valores más elevados de leucocitosis y neutrofilia fueron observados en pacientes con AAQI por absceso hepático, resultado que concuerda con una revisión de 2016. (9) Los bacilos Gram negativos constituyeron los agentes etiológicos más frecuentemente aislados en las IIA en este estudio, en orden de frecuencia : E s c h e r i c h i a c o l i , K l e b s i e l l a p n e u m o n i a e y P s e u d o m o n a s a e r u g i n o s a , como principales agentes. Se halló un resultado muy parecido en un estudio de 2015 el cual reportó que los Gram negativos más comunes fueron: E. coli 65,1%, K. pneumoniae 9,4% y P. aeruginosa 8,9%. ...
Objetivo: caracterizar los microorganismos involucrados en las infecciones intraabdominales, y fenotipificar sus perfiles de resistencia al uso de los antibióticos en el Servicio de Cirugía General del Instituto Autónomo Hospital Universitario de Los Andes, entre los años 2014 al 2017. Metodología: enfoque cuantitativo; tipo descriptivo, diseño no experimental de estudio de casos y transversal, a través de toma de muestras de secreciones abdominales en quirófano a las cuales se les realizó cultivo en medios de agar sangre y McConkey, tinción Gram, contaje de leucocitos, y prueba Kirby-Bauer de sensibilidad antimicrobiana. Muestra de 211 pacientes mayores de 16 años que acudieron a la institución con el diagnóstico de abdomen agudo quirúrgico infeccioso. Resultados: el abdomen agudo quirúrgico infeccioso por apendicitis aguda fue la infección intraabdominal más común, grupo etario que acudió con más frecuencia: <26 años. Agentes etiológicos más frecuentemente aislados: bacilos Gram negativos, especies más frecuentes: E. coli (57,3%), K. pneumoniae (10,9%) y P. aeruginosa (6,16%). De todos los microorganismos aislados 57,6% expresaron al menos un fenotipo de resistencia. Fenotipo más común: betalactamasa de espectro extendido y bomba de eflujo de quinolonas (18,8%). Microorganismos con mayores porcentajes de resistencia: Staphylococcus sp. y Enterococcus sp (~100%). Los mejores porcentajes de sensibilidad de la E. coli, K. pneumoniae y P. aeruginosa fueron hacia al colistin, carbapenémicos y amikacina (100%). Conclusión: Los carbapenémicos y los aminoglucósidos seguirán siendo los fármacos de elección en las infecciones intraabdominales del Instituto Autónomo Hospital Universitario de Los Andes.
... The diagnosis of liver abscess needs to be confirmed by ultrasound, CT, or magnetic resonance imaging (MRI), especially the differentiation between liver abscess and liver metastasis [5][6][7]. The incidence of liver abscess in ablation patients was 0.1% to 0.7%, while the incidence of liver abscess was significantly increased in patients with enterobiliary anastomosis [8]. The incidence of liver abscess after liver intervention in patients who had undergone Whipple surgery was up to 86%. ...
... Now the mortality rate for patients with liver abscesses has decreased significantly, but it is still close to 15%. Factors that increase the risk of death in patients with liver abscess include advanced age, malignancy, diabetes, abscess > 5 cm, low immunity, multiple organ failure, PPI use, and cirrhosis, etc [8]. When patients with liver abscess are complicated by COVID-19, the mortality is still as high as 55% even after early drainage and antibiotic treatment [10,11]. ...
Background:
Liver interventional surgery is a relatively safe and minimally invasive surgery. However, for patients who have undergone Whipple surgery, the probability of developing a liver abscess after liver interventional surgery is very high. Fungal liver abscess has a high mortality rate, especially when complicated with malignant tumors, diabetes, coronavirus disease 2019 (COVID-19) and other complications. Fungal liver abscess is rare, and there are no guidelines or expert consensus on the course of antifungal therapy.
Case summary:
A 54-year-old woman with pancreatic head cancer received albumin-bound paclitaxel in combination with gemcitabine chemotherapy after laparoscopic pancreaticoduodenectomy. Liver metastasis was found 1 mo after completion of 8 cycles of chemotherapy, followed by ablation of the liver metastasis. After half a month of liver metastasis ablation, the patient experienced fever after chemotherapy and was diagnosed with liver abscess complicated with COVID-19 by contrast-enhanced abdominal computed tomography and real-time polymerase chain reaction detection. The results of pus culture showed Candida albicans, which was sensitive to fluconazole. The patient underwent percutaneous catheter drainage, antifungal therapy with fluconazole, and antiviral therapy with azvudine. During antifungal therapy, the patient showed a significant increase in liver enzyme levels and was discharged after liver protection therapy. Oral fluconazole was continued for 1 wk outside the hospital, and fluconazole was used for a total of 5 wk. The patient recovered well and received 4 cycles of fluorouracil, leucovorin, oxaliplatin, and irinotecan after 2 mo of antifungal therapy.
Conclusion:
Effective treatment of Candida albicans liver abscess requires early detection, percutaneous catheter drainage, and 5 wk of antifungal therapy. Meanwhile, complications such as COVID-19 should be actively managed and nutritional support should be provided.
... In contrast, our study revealed an increased risk of sepsis in PLA patients with a positive blood culture alone. For the treatment of PLA, abscess drainage and administration of appropriate antibiotics are the primary therapeutic modalities 17,18 . The choice of antibiotic should be based on the suspected source of infection and the predominant pathogens in the region. ...
Pyogenic liver abscess (PLA) is a severe condition that significantly increases the risk of sepsis. However, there is a notable dearth of research regarding the prediction of sepsis in PLA patients. The objective of this study was to develop and validate a prognostic nomogram for predicting sepsis in PLA patients. A total of 206 PLA patients were enrolled in our study, out of which 60 individuals (29.1%) met the Sepsis-3 criteria. Independent risk factors for sepsis were identified through univariate and multivariate logistic regression analyses. Subsequently, a nomogram was developed based on age, positive blood culture, procalcitonin, alanine aminotransferase, blood urea nitrogen, and d-dimer. The nomogram demonstrated excellent calibration and discrimination, as evidenced by the area under the receiver operating characteristic curve (AUC) values of 0.946 (95% confidence interval [CI], 0.912–0.979) and 0.980 (95%CI 0.951–1.000) in the derivation and validation cohorts, respectively. Furthermore, decision-curve analysis confirmed the clinical utility of the nomogram. This study provides valuable insights for the prevention of sepsis in PLA patients and underscores the potential application of the prognostic nomogram in clinical practice.
... Pyogenic liver abscess (PLA) is a common intraperitoneal infection with several risk factors, such as diabetes mellitus (DM) and underlying hepatobiliary or pancreatic disease (Chadwick et al., 2018;Mukthinuthalapati et al., 2020). Although the mortality rate has improved, a significant percentage of PLA patients develop complications including extrahepatic migratory infection (EMI), abscess rupture and so on (Mavilia et al., 2016). DM is a predisposing factor for PLA (Thomsen et al., 2007;Mavilia et al., 2016); PLA patients with DM tend to have a higher prevalence of metastatic infection, bacteremia, multi-organ dysfunction syndrome and intensive care unit (ICU) admission (Foo et al., 2010;Tian et al., 2012). ...
... Although the mortality rate has improved, a significant percentage of PLA patients develop complications including extrahepatic migratory infection (EMI), abscess rupture and so on (Mavilia et al., 2016). DM is a predisposing factor for PLA (Thomsen et al., 2007;Mavilia et al., 2016); PLA patients with DM tend to have a higher prevalence of metastatic infection, bacteremia, multi-organ dysfunction syndrome and intensive care unit (ICU) admission (Foo et al., 2010;Tian et al., 2012). The mechanism underlying this phenomenon is not fully understood, so it is important to better understand the relevant mechanism, which can be used to develop preventive and treatment strategies. ...
Introduction
Pyogenic liver abscess (PLA) patients combined with diabetes mellitus (DM) tend to have more severe clinical manifestations than without DM. The mechanism responsible for this phenomenon is not entirely clear. The current study therefore aimed to comprehensively analyze the microbiome composition and metabolome in pus from PLA patients with and without DM, to determine the potential reasons for these differences.
Methods
Clinical data from 290 PLA patients were collected retrospectively. We analyzed the pus microbiota using 16S rDNA sequencing in 62 PLA patients. In addition, the pus metabolomes of 38 pus samples were characterized by untargeted metabolomics analysis. Correlation analyses of microbiota, metabolites and laboratory findings were performed to identify significant associations.
Results
PLA patients with DM had more severe clinical manifestations than PLA patients without DM. There were 17 discriminating genera between the two groups at the genus level, among which Klebsiella was the most discriminating taxa. The ABC transporters was the most significant differential metabolic pathway predicted by PICRUSt2. Untargeted metabolomics analysis showed that concentrations of various metabolites were significantly different between the two groups and seven metabolites were enriched in the ABC transporters pathway. Phosphoric acid, taurine, and orthophosphate in the ABC transporters pathway were negatively correlated with the relative abundance of Klebsiella and the blood glucose level.
Discussion
The results showed that the relative abundance of Klebsiella in the pus cavity of PLA patients with DM was higher than those without DM, accompanied by changes of various metabolites and metabolic pathways, which may be associated with more severe clinical manifestations.
... The majority of liver abscesses in the United States and other Western countries are classified as pyogenic (bacterial) followed by amebic and more rarely fungal infections [4]. Pyogenic liver abscesses (PLA) are often polymicrobial with the common organisms being Klebsiella, E. coli, Streptococcus, and anaerobes [3]. ...
... The most common identifiable cause of PLA is due to biliary tract infection (30-50%) including gallstone disease, obstructing tumors, and strictures. Known risk factors include diabetes mellitus, liver surgery/transplant, liver cirrhosis, malignancy, immunosuppression, chronic use of proton pump inhibitors (PPI), and advanced age [4]. ...
... First, malignant liver abscesses with necrotic cores can also develop bacterial infections, causing gas-containing lesions that appear solitary in primary hepatocellular carcinoma or multiple in metastases. 7 Liver metastases can occur with ovarian cancer, which was a concern in this patient who had a prominent left ovary and post-menopausal vaginal discharge. However, the relatively short history of symptoms without unintentional weight loss, thin-walled appearance of the PLA and absence of multiple liver lesions made malignancy unlikely. ...
Pyogenic liver abscess (PLA) commonly occurs in the right liver lobe, causing the typical symptoms of fever and right upper quadrant pain. Less than one-third of cases occur in the left lobe. We describe an unusual presentation of a giant left-sided PLA that was compressing the stomach and surrounding venous vasculature, causing the respective symptoms of gastro-oesophageal reflux and vaginal discharge from secondary pelvic congestion syndrome. CT revealed a solitary 14 cm×10 cm×10 cm multiloculated lesion, replacing most of the left liver lobe. It was successfully treated with intravenous antibiotics and percutaneous drainage, resulting in complete resolution at 1-year follow-up. This case explores the predisposing risk factor of diabetes in PLA and its association with Klebsiella pneumoniae, which was the offending pathogen in our patient. We also discuss the phenomenon of secondary pelvic venous congestion syndrome and compare similar cases of left-sided PLA, highlighting the different modes of presentation and treatment options.
... Similarly, the mode of transmission from the pelvis to the inferior right lobe of the liver is a highly unusual finding. Etiologies of liver abscesses can be classified as infectious, metastatic, or iatrogenic [8]. For infectious sources, the most common pathway is through the biliary tree (e.g. ...
Postpartum infectious complications can present with a wide range of nonspecific symptoms. Herein, we describe a complicated late postpartum presentation of recurrent fever following a cesarean delivery complicated by chorioamnionitis. Following discharge, the patient experienced cyclical fever and was treated with antipyretics as an outpatient. The patient continued to experience symptoms and reported to the hospital for further evaluation. Initially thought to be septic pelvic thrombophlebitis, the patient was trialed on clindamycin and gentamycin without resolution of symptoms. After extensive evaluation, the fevers were found to be the result of an infected periuterine hematoma and a concomitant subcapsular inferior hepatic abscess. Bacterial cultures isolated two rare anaerobic organisms: Peptoniphilus ssp. and Finegoldia magna. Source control was achieved by drainage of the two abscesses followed by antibiotic treatment with ertapenem and metronidazole, and the patient recovered successfully. This is the first reported case, to the authors' knowledge, of this complicated postpartum picture due to these anaerobic organisms.
