Unique characteristics of pyogenic liver abscesses of biliary origin

Clinical characteristics of pyogenic liver abscess with and without biliary surgery history: a retrospective single-center experience

BACKGROUND & AIMS

Pyogenic liver abscess (PLA) is a common hepatobiliary infection that has been shown to have an increasing incidence, with biliary surgery being identified as a trigger. Our aim was to investigate the clinical characteristics and treatments of PLA patients with and without a history of biliary surgery (BS).

METHODS

The study included a total of 353 patients with PLA who received treatment at our hospital between January 2014 and February 2023. These patients were categorized into two groups: the BS group (n = 91) and the non-BS group (n = 262). In the BS group, according to the anastomosis method, they were further divided into bilioenteric anastomoses group (BEA, n = 22) and non-bilioenteric anastomoses group (non-BEA, n = 69). Clinical characteristics were recorded and analyzed.

RESULTS

The percentage of PLA patients with BS history was 25.78%. The BS group exhibited elevated levels of TBIL and activated APTT abnormalities (P = 0.009 and P = 0.041, respectively). Within the BS group, the BEA subgroup had a higher prevalence of diabetes mellitus (P < 0.001) and solitary abscesses (P = 0.008) compared to the non-BEA subgroup. Escherichia coli was more frequently detected in the BS group, as evidenced by positive pus cultures (P = 0.021). The BS group exhibited reduced treatment efficacy compared to those non-BS history (P = 0.020). Intriguingly, the BS group received a higher proportion of conservative treatment (45.05% vs. 21.76%), along with reduced utilization of surgical drainage (6.59% vs. 16.41%).

CONCLUSIONS

Patients with BS history, especially those who have undergone BEA, have an increased susceptibility to PLA formation without affecting prognosis.

Pyogenic liver abscesses in liver transplant recipients versus non-transplant population. Outcome and risk factors of patient survival

Pyogenic liver abscess (PLA) is a life-threatening infection in both liver transplant (LT) and non-LT patients. Several risk factors, such as benign and malignant hepatopancreatobiliary diseases and colorectal tumors have been associated with PLA in the non-LT population, and hepatic artery stricture/thrombosis, biliary stricture, and hepaticojejunostomy in the LT patients. The objective of this study is to compare the outcomes of patients with PLA in LT and non-LT patients and to determine the risk factors associated with patient survival. From January 2000 to November 2020, a total of 296 adult patients were diagnosed of PLA in our institution, of whom 26 patients had previously undergone liver transplantation (LTA group), whereas 263 patients corresponded to the non-LTA population. Seven patients with PLA who had undergone previous kidney transplantation were excluded from this retrospective study. Twenty-six patients out of 1503 LT developed PLA (incidence of 1.7%). Median age was significantly higher in non-LTA patients (p = .001). No significant differences were observed in therapy. PLA recurrence was significantly higher in LTA than in non-LTA (34.6% vs. 14.8%; p = .008). In-hospital mortality was greater in the LT group than in the non-LT group (19.2% vs. 9.1% p = .10) and was identified in multivariable analysis as a risk factor for mortality (p = .027). Mortality rate during follow-up did not show significant differences between the groups: 34.6% in LTA patients versus 26.2% in non-LTA patients (p = .10). The most common causes of mortality during follow-up were malignancies, Covid-19 infection, and neurologic disease. 1-, 3-, and 5-year actuarial patient survival rates were 87.0%, 64.1%, and 50.4%, respectively, in patients of LTA group, and 84.5%, 66.5%, and 51.0%, respectively, in patients with liver abscesses in non-LTA population (p = .53). In conclusion, LT was a risk factor for in hospital mortality, but not during long-term follow-up.

Risk factors indicating the need for surgical therapy in patients with pyogenic liver abscesses

BACKGROUND

Percutaneous drainage (PD) and antibiotics are the therapy of choice (non-surgical therapy [non-ST]) for pyogenic liver abscesses (PLA), reserving surgical therapy (ST) for PD failure. The aim of this retrospective study was to identify risk factors that indicate the need for ST.

METHODS

We reviewed the medical charts of all of our institution's adult patients with a diagnosis of PLA between January 2000 and November 2020. A series of 296 patients with PLA was divided into two groups according to the therapy used: ST (n = 41 patients) and non-ST (n = 255). A comparison between groups was performed.

RESULTS

The overall median age was 68 years. Demographics, clinical history, underlying pathology, and laboratory variables were similar in both groups, except for the duration of PLA symptoms < 10 days and leukocyte count which were significantly higher in the ST group. The in-hospital mortality rate in the ST group was 12.2% vs. 10.2% in the non-ST group (p = 0.783), with biliary sepsis and tumor-related abscesses as the most frequent causes of death. Hospital stay and PLA recurrence were statistically insignificant between groups. One-year actuarial patient survival was 80.2% in the ST group vs. 84.6% in the non-ST (p = 0.625) group. The presence of underlying biliary disease, intra-abdominal tumor, and duration of symptoms for less than 10 days on presentation comprised the risk factors that indicated the need to perform ST.

CONCLUSIONS

There is little evidence regarding the decision to perform ST, but according to this study, the presence of underlying biliary disease or an intra-abdominal tumor and the duration of PLA symptoms < 10 days upon presentation are risk factors that should sway the surgeons to perform ST instead of PD.

Risk Factors for Infections, Antibiotic Therapy, and Its Impact on Cancer Therapy Outcomes for Patients with Solid Tumors

Infections represent a significant cause of morbidity and mortality in cancer patients. Multiple factors related to the patient, tumor, and cancer therapy can affect the risk of infection in patients with solid tumors. A thorough understanding of such factors can aid in the identification of patients with substantial risk of infection, allowing medical practitioners to tailor therapy and apply prophylactic measures to avoid serious complications. The use of novel treatment modalities, including targeted therapy and immunotherapy, brings diagnostic and therapeutic challenges into the management of infections in cancer patients. A growing body of evidence suggests that antibiotic therapy can modulate both toxicity and antitumor response induced by chemotherapy, radiotherapy, and especially immunotherapy. This article provides a comprehensive review of potential risk factors for infections and therapeutic approaches for the most prevalent infections in patients with solid tumors, and discusses the potential effect of antibiotic therapy on toxicity and efficacy of cancer therapy.

Analysis of the clinical characteristics of 202 patients with liver abscess associated with diabetes mellitus and biliary tract disease

OBJECTIVE

Clinical characteristics of patients with pyogenic liver abscess (PLA) of varying etiologies may be different. This study aimed to analyze the clinical characteristics, pathogenic bacteria, treatment, and prognosis of patients with PLA associated with diabetes and biliary disease.

METHODS

Clinical, imaging, and laboratory data from 202 inpatients with PLA were retrospectively analyzed.

RESULTS

Eighty-eight patients (43.6%) had a history of diabetes, 73 (36.1%) had a history of underlying biliary tract disease, and 24 (11.9%) had both the diseases. The level of C-reactive protein (CRP) increased in 99.2% (119/120) patients, and the level of procalcitonin (PCT) increased in 95.5% (148/155) patients. The main pathogen of PLA was Klebsiella pneumoniae. The incidence of bloodstream infection increased by 34.4% (22/64) in patients with PLA that was associated with diabetes mellitus, and that of K. pneumoniae infection was 88.6% (39/44). The readmission rate for patients with PLA with underlying biliary diseases was 10.2 to 12.5%.

CONCLUSION

The main pathogen of PLA is K. pneumoniae, which is sensitive to most antibiotics. Patients with PLA associated with diabetes were more likely to have bloodstream infections, and the recurrence rate of PLA with underlying biliary diseases was higher than without biliary duct disease.

Particulars of Medical and Surgical Treatment of Liver Abscess in Septic Patient– Case Report

First described by Bright in 1836, who reports two cases secondary to suppurative angiocolitis and pilephlebitis, intrahepatic suppurations were, until the era of the discovery of antibiotics, one of the most dreaded causes of mortality, reaching a rate of almost 100%. Today, both the incidence of liver abscesses and the mortality rate have been significantly reduced, as the introduction of antibiotics has dramatically reduced the number of septic piles due to peritoneal outbreaks. Their etiology is more recently, most frequently, a biliary or neoplastic disease. On the other hand, the improvement of germ isolation techniques has made it possible to identify anaerobic germs with maximum frequency, and diagnostic and treatment performance has increased so much with the advent of non-invasive or minimally-invasive procedures that the overall mortality rate of 70% in 1975 is now about 30–38%.

We present the case of a 75-year-old male patient with no known history of ilnesses who is admitted for fever, chills, myalgia, arthralgia and visual disturbances with onset of approximately one week. Biologically he presents with leukocytosis with marked neutrophilia, mild thrombocytopenia and significant biological inflammatory syndrome. Suspicion is raised for a diagnosis of Sepsis with unspecified starting point with possible pyogenic cavernous sinus thrombosis, a complication suggested by the presence of visual disturbances. Neuro-imaging evaluation by CT and brain MRI is performed, with the diagnosis of thrombosis being refuted. Abdominal CT is performed which identifies a space replacement formation in the left hepatic lobe for which MRI evaluation is required. MRI detects an expansive hepatic formation with semiology suggestive of liver abscess. Treatment was instituted with a combination of broad-spectrum antibiotics and antifungal treatment, but the evolution was unfavourable with maintenance of leukocytosis with marked neutrophilia and progression of inflammatory samples. It was necessary to evaluate the case by a multidisciplinary team (infectious disease specialist, gastroenterologist, surgeon) to establish the appropriate therapeutic management, with surgical resolution of the case, with a favourable postoperative evolution.

Increased incidence of and microbiologic changes in pyogenic liver abscesses in the Mexican population

BACKGROUND

Pyogenic liver abscess (PLA) is a rare disease with an estimated incidence that varies widely across the globe, being as high as 115.4/100000 habitants in Taiwan and as low as 1.1-1.2/100000 habitants in Europe and Canada. Even though there are multiple microorganisms capable of producing an abscess in the liver, including Entamoeba histolytica, fungi, and viruses, most abscesses are derived from bacterial infections. The epidemiology of PLA in Mexico is currently unknown.

AIM

To describe the clinical, demographic and microbiologic characteristics of PLA in Mexico.

METHODS

This is a retrospective study carried out in two centers, and included patients seen between 2006 and 2018 with the diagnosis of pyogenic abscess. We collected demographic, clinical, and microbiological information, treatment, complications, and outcomes. A logistic regression analysis was used to determine the association between different variables and mortality rates.

RESULTS

A total of 345 patients were included in this study. 233 (67.5%) had confirmed PLA, 133 (30%) patients had no positive culture and negative serology and 9 (2.5%) had mixed abscesses. The mean age was 50 years (ranging from 16-97 years) and 63% were female. 65% of the patients had positive cultures for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia coli and Klebsiella pneumoniae. Cefotaxime was administered in 60% of cases. The most common sources of infection were ascending cholangitis and cholecystitis in 34 (10%) and 31 (9%), respectively. The median length of hospital stay was 14 d. 165 patients underwent percutaneous catheter drainage. The inpatient mortality rate was 63%. Immunocompromised state [OR 3.9, 95%CI: 1.42-10.46], ESBL- Escherichia coli [OR 6.7, 95%CI: 2.7-16.2] and Klebsiella pneumoniae [OR 4-8, 95%CI: 1.6-14.4] predicted inpatient mortality by multivariate analysis.

CONCLUSION

The prevalence of PLA is increasing in Mexico and has a very high mortality rate. ESBL-Escherichia coli and Klebsiella pneumoniae are the most common microorganisms causing PLA and are independent predictors of inpatient mortality.

Pyogenic liver abscess in liver transplant recipient: A warning signal for the risk of recurrence and retransplantation

BACKGROUND

Pyogenic liver abscesses in liver transplant recipients (PLA-LTR) are a rare disease whose specificities compared with PLA in non-transplanted patients (PLA-C) are unknown.

METHODS

A retrospective case-control study was conducted in a French academic hospital from January 1, 2010, to December 31, 2014.

RESULTS

Among 176 patients diagnosed with PLA, 14 were LTR; each case was matched with 3 PLA-C controls by date of PLA diagnosis and pathophysiological mechanism of PLA. Median time from liver transplantation to PLA diagnosis was 34.5 months. Among 14 PLA-LTR, 8/14 (57.1%) had bacteremia and 10/14 (71.4%) had positive PLA cultures. Most commonly isolated bacteria were Enterobacteriaceae (9/14; 64.3%), Enterococcus spp. (4/14; 28.6%), and anaerobic bacteria (3/14; 21.4%). Clinical, radiological, and microbiological characteristics did not significantly differ between PLA-LTR and PLA-C but there was a tendency toward more diabetic patients and a less acute presentation. All but one PLA-LTR were associated with ischemic cholangitis, whereas this was a rare cause among PLA-C (13/14 vs 3/42, respectively, P < .001) among patients with PLA-LTR. In contrast, hepatobiliary neoplasia was rare in PLA-LTR but frequent in PLA-C (1/14 vs 24/42, P = .001). No significant difference was found between PLA-LTR and PLA-C in terms of duration of antibiotic therapy (6.5 and 6 weeks, respectively), PLA drainage rates (10/14 and 26/42, respectively), or mortality at 12 months after PLA diagnosis (2/14 and 5/42, respectively). Recurrence rates within the first year were observed in 6/14 patients (42.9%), and retransplantation was needed in 5/14 (35.7%).

CONCLUSIONS

Occurrence of PLA in LTR is a severe event leading to high risk of recurrence and retransplantation.

Clinical, microbiological, and molecular epidemiological characteristics of Klebsiella pneumoniae-induced pyogenic liver abscess in southeastern China

Background

Klebsiella pneumoniae-induced pyogenic liver abscess (KP-PLA) has emerged as a life-threatening disease worldwide. However, to date, a limited number of scholars have attempted to systematically elucidate the characteristics of KP-PLA. The aim of the present study was to analyze clinical, microbiological, and molecular epidemiological characteristics of KP-PLA patients in Southeastern China.

Methods

The KP-PLA cases from a tertiary teaching hospital in China from January 2016 to December 2017 were systemically studied and elucidated comprehensively. The virulence factors, resistant spectrum, and clones of K. pneumoniae isolates were identified with string test, polymerase chain reaction (PCR), antimicrobial susceptibility test, and multilocus sequence typing. Moreover, the characteristics in KP-PLA patients with and without other hepatobiliary diseases (OHD) were also been compared.

Results

A total of 163 KP-PLA cases were enrolled, in which the majority of those cases were senior males, and often associated with multiple underlying diseases, including diabetes (49.7%). The remaining cases belonged to healthy individuals (50.3%). The clinical symptoms were common but nonspecific, characterized by increased inflammatory parameters and abnormal liver function parameters. The abscess was often right-sided solitary presentation (58.3%). Cephalosporin or carbapenem plus metronidazole combined with percutaneous puncture or catheter drainage were favorable therapeutics. Although low resistance rates of commonly used antimicrobial drugs (< 10%) were observed, twelve strains were identified as multidrug resistant (MDR) strains, and were mainly isolated from the OHD patients. The hypermucoviscosity, as well as K1 and K2 serotypes accounted for 30.7, 40.5, and 19.0%, respectively. Except for iroN (24.5%) and magA (45.4%), the high prevalence of virulence genes (e.g. aerobactin, rmpA, mrkD, fimH, uge, ureA, entB, ybtA, kfuBC, and wcaG) was identified (68.7–100.0%). Additionally, ST23 was found as a predominant sequence type (ST; 38.7%), and three novel STs (ST3507, ST3508 and ST3509) were noted as well.

Conclusions

The present study reported the abundant hvKp strains in KP-PLA, as well as convergence of hypervirulent and MDR K. pneumoniae isolates from the KP-PLA patients, particularly those cases with OHD. Given the various clinical manifestations and destructive pathogenicity, determination of the comprehensive characteristics of such isolates is highly essential to effectively carry out for optimal management and treatment of KP-PLA.

Cryptogenic and non-cryptogenic liver abscess: A retrospective analysis of 178 cases revealed distinct characteristics

Objective

To enhance theoretical support of pyogenic liver abscess (PLA) treatment by comparing characteristics of patients with either PLA with an identified infectious origin (non-cryptogenic) or PLA with no obvious underlying cause (cryptogenic).

Methods

This retrospective study included all first episodes of PLA in adults admitted to a tertiary hospital between 2009 and 2016. Relevant clinical data were collected for patients with cryptogenic or non-cryptogenic PLA and compared across a number of characteristics.

Results

In all, 178 patients were included: 111 cases (62.4%) of cryptogenic PLA, and 67 cases (37.6%) of non-cryptogenic PLA. Diabetes mellitus was significantly more prevalent in patients with cryptogenic PLA than those with non-cryptogenic PLA. The proportion of multidrug resistance/poly-microbial infection was significantly lower and Klebsiella pneumoniae infection was significantly higher in the cryptogenic versus non-cryptogenic PLA group. Metastatic infection occurred in four patients with cryptogenic PLA only, and all had diabetes and K. pneumoniae infection. Multivariate logistic regression analysis revealed that male sex, diabetes and K. pneumoniae were independent predictors for cryptogenic PLA.

Conclusions

Cryptogenic and non-cryptogenic PLA have distinctly different characteristics, suggesting a potential need for different treatment approaches.

Pyogenic liver abscess related to intrahepatic bile duct stones: Difficulties in infectious control and diagnosis of concomitant cholangiocarcinoma

BACKGROUND AND AIM

Cholangitis, bacteremia, and pyogenic liver abscess (PLA) can be often caused by intrahepatic bile ducts stone (IBDS), which is endemic to South-East Asia. The association between IBDS and cholangiocarcinoma has been well recognized. Concomitant cholangiocarcinoma in the PLA related to IBDS is often missed.

METHODS

A case-control study consisting of 64 patients with PLA related to IBDS and 256 control patients with PLA not related to IBDS was used to investigate clinical features of PLA and incidence of concomitant cholangiocarcinoma in patients with PLA related to IBDS.

RESULTS

The main imaging manifestations of PLA related to IBDS was cystic-solid lesions and solid lesions. Of seven patients (10.9%) with pathology-proven cholangiocarcinoma in the same area of PLA related to IBDS among 64 patients, only two patients were initially diagnosed as having concomitant cholangiocarcinoma by biopsy, and other five patients diagnosed as acute inflammatory lesion. Within 60 days after onset, the infection-related death rate and recurrence rate in patients with PLA related to IBDS were 12.9% and 20.3%, respectively, whereas in patients with PLA not related to IBDS were 3.9% and 3.1%, respectively. Only 25% of patients with PLA related to IBDS underwent surgery after admission. The main pathogens in PLA patients related to IBDS were Escherichia coli and extended-spectrum beta-lactamase-producing Enterobacteriaceae.

CONCLUSIONS

The imaging manifestations of PLA related to IBDS often present cystic-solid or solid lesions. PLA related to IBDS is characterized by high rate of recurrence and infection-related death, difficulty in diagnosis of concomitant cholangicarcinoma.

Biliary diseases as main causes of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae

BACKGROUND & AIMS

Little is known about aetiology and morbidity and clinical characteristics of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae.

METHODS

An analysis between pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates and those caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae was performed.

RESULTS

Among 817 pyogenic liver abscess patients, there were 176 patients (21.5%) with pyogenic liver abscess of biliary origin, and 67 pyogenic liver abscess patients (8.2%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates (mainly Escherichia coli and Klebsiella pneumoniae). Of 176 pyogenic liver abscess patients related to biliary disorders, there were 48 pyogenic liver abscess patients (27.3%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Within 67 pyogenic liver abscess patients caused by Enterobacteriaceae expressing extended-spectrum beta-lactamases, the occurrences of 48 pyogenic liver abscess patients (71.6%) were associated with biliary disorders. When compared with pyogenic liver abscess patients caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae, there were significantly greater incidences of polymicrobial infections, bacteremia, pulmonary infection, recurrence and death in pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Carbapenems remain mainstay drugs against extended-spectrum beta-lactamase-producing E. coli and K. pneumoniae. Independent risk factors for occurrence of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae were biliary disorders including extra- and intrahepatic cholangiolithiasis and an abnormal bilioenteric communication between bile and gut, a treatment history of malignancy such as operation and chemotherapy, pulmonary infection, and diabetes mellitus.

CONCLUSIONS

Pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates mainly occurs in patients with biliary disorders or with a treatment history of malignancy. The mainstay of treatment remains carbapenems in combination with adequate aspiration or drainage.

Infections in Cancer Patients with Solid Tumors: A Review

Solid tumors are much more common than hematologic malignancies. Although severe and prolonged neutropenia is uncommon, several factors increase the risk of infection in patients with solid tumors, and the presence of multiple risk factors in the same patient is not uncommon. These include obstruction (most often caused by progression of the tumor), disruption of natural anatomic barriers such as the skin and mucosal surfaces, and treatment-related factors such as chemotherapy, radiation, diagnostic and/or therapeutic surgical procedures, and the increasing use of medical devices such as various catheters, stents, and prostheses. Common sites of infection include the skin and skin structures (including surgical site infections), the bloodstream (including infections associated with central venous catheters), the lungs, the hepato-biliary and intestinal tracts, and the urinary tract, and include distinct clinical syndromes such as post-obstructive pneumonia, obstructive uropathy, and neutropenic enterocolitis. The epidemiology of most of these infections is changing with resistant organisms [MRSA, Pseudomonas aeruginosa, extended spectrum beta-lactamase (ESBL)-producing organisms] being isolated more often than in the past. Polymicrobial infections now predominate when deep tissue sites are involved. Conservative management of most of these infections (antibiotics, fluid and electrolyte replacement, bowel rest when needed) is generally effective, with surgical intervention being reserved for the drainage of deep abscesses, or to deal with complications such as intestinal obstruction or hemorrhage. Infected prostheses often need to be removed. Reactivation of certain viral infections (HBV, HCV, and occasionally CMV) has become an important issue, and screening, prevention and treatment strategies are being developed. Infection prevention, infection control, and antimicrobial stewardship are important strategies in the overall management of infections in patients with solid tumors. Occasionally, infections mimic solid tumors and cause diagnostic and therapeutic challenges.