Predictors of septic shock in initially stable patients with pyogenic liver abscess

Socioeconomic Burden of Pyogenic Liver Abscess Caused by Klebsiella Pneumoniae from a Teaching Hospital in East China

Background

The prevalence of pyogenic liver abscess (PLA) is increasing worldwide. However, evaluation on its economic burden is still lack.

Methods

A retrospective study that included all patients identified PLA from 2017 to 2020 was conducted. Clinical information and hospital costs were collected through the electronic medical records. We evaluated the economic burden using disability-adjusted life years (DALYs). Differences in socioeconomic burdens between Klebsiella pneumoniae-caused liver abscesses (KPLA) and non-Klebsiella pneumoniae-caused liver abscesses (non-KPLA) were compared.

Results

We found 327 patients identified PLA in the study, including 146 with KPLA and 181 with non-KPLA. The demographic characteristics, median hospital stay, severity, and in-hospital mortality were similar between the two groups. The median total in-hospital cost was higher in the non-KPLA than in the KPLA group, although no statistical difference was found ($3607.2 vs $3424.6; P = 0.446). The median DALY loss was significantly higher in the KPLA than in the non-KPLA group [1.49 (0.97-2.30) vs 1.27 (0.87-1.89); P = 0.033)], and male patients presented a higher average DALY loss than female patients. KPLA had a substantially greater median indirect economic loss than the non-KPLA group [$1442.8 (915.9-17,221.5) vs $1232.5 (764.6-15,473.0); P = 0.028], and indirect economic loss exhibited a significant increase from 2017 to 2020 in patients with PLA. No differences were found in the socioeconomic burden between the two groups [$8019.6 (4200.3-21,832.1) vs $7436.4 (4023.2-19,063.9); P = 0.172].

Conclusion

The economic burden of PLA is significant, particularly in patients with KP. Patients with KPLA experienced increased DALY loss and indirect economic loss than non-KPLA. PLA must be prioritized as the indirect economic burden rises annually.

Decoding pylephlebitis: Tracing the path of infected thrombosis and liver abscesses

Pylephlebitis, a septic thrombophlebitis of the portal vein, is an uncommon but serious complication following an abdominal site of infection, most frequently diverticulitis or appendicitis. It has a high mortality rate, yet it commonly presents with unspecific abdominal complaints and fever, making diagnosis by clinical and laboratory examinations alone, impossible. This report highlights the extensive computed tomography (CT) findings of pylephlebitis with multiple hepatic abscesses thought to be secondary to diverticulitis, in a patient presenting with septic shock. Radiological characteristics differentiating the liver lesions from malignancy, and showing the ascending pathway of vascular involvement from the inferior mesenteric vein to portal veins is presented, as well as the search for the primary site of infection. Recognizing and understanding the imaging findings in pylephlebitis is crucial for diagnosis and avoiding delay of appropriate treatment for this otherwise often fatal condition.

The New Changes of Epidemiology, Etiology, and Clinical Characteristics of Pyogenic Liver Abscesses: A Retrospective Study in a Hospital in Northern China

Purpose

To investigate the epidemiology, etiology, and clinical characteristics of patients with pyogenic liver abscesses (PLA) and provide guidance for clinical treatments.

Patients and Methods

A retrospective study was performed on a cohort of 402 hospitalized patients diagnosed with PLAs at the Affiliated Hospital of Chengde Medical College between January 2016 and December 2021. Patient demographics, drug sensitivity profiles, and microbiological culture results of drainage and blood samples were thoroughly analyzed to identify significant patterns or trends. Furthermore, clinical characteristics and treatments for patients with PLA were comprehensively assessed.

Results

Patients aged 50-69 years had the highest incidence of PLA, accounting for 59.9% of all cases, and 91.5% of them had a fever. Bacterial culture analysis of the 200 patients revealed that Klebsiella pneumoniae (K. pneumoniae) was the most predominant pathogen, detected in 70.5% of cases, exhibiting an upward trend. Escherichia coli (E. coli) was the second most frequently detected pathogen, identified in 14.5% of cases, showing a downward trend. Coexisting diabetes mellitus (DM) was found to be the most common comorbidity for PLA, occurring in most patients with the condition. Patients with a history of abdominal surgery and malignancy had an increased risk for PLA, while those with gallstones had a decreased risk. Drainage combined with antibiotic therapy was identified as the primary treatment of PLA. In addition, multivariate analysis demonstrated that coexisting DM and the presence of gas in the abscess cavity were independent risk factors for septic shock in patients with PLA.

Conclusion

This study reveals a shift in the proportions of pathogens and risk factors in patients with PLA, underscoring the necessity for improved diagnostic and therapeutic strategies.

The influence of early adoption of nonenhanced computed tomography on management of patients with pyogenic liver abscess

Background and Aim

A pyogenic liver abscess (PLA) is an infectious disease with high in-hospital mortality. It has no specific symptoms and is difficult to be diagnosed early in the emergency department. Ultrasound is commonly used to detect PLA lesions of PLA, but its sensitivity can be affected by lesion size, location, and clinician experience. Therefore, early diagnosis and prompt treatment (especially abscess drainage) are crucial for better patient outcomes and should be prioritized by clinical physicians.

Methods

We conducted a retrospective study to compare the effect of early and late (i.e., receiving CT scanning within 48 h and >48 h after admission) adoption of nonenhanced computed tomography (CT) scanning regarding the hospitalization days and interval between admission and drainage of patients with PLA.

Results

This study included 76 hospitalized patients with PLA in the Department of Digestive Disease of Xiamen Chang Gung Hospital in China who underwent CT examinations from 2014 to 2021. We conducted CT scans on 56 patients within 48 h of admission and on 20 patients more than 48 h after admission. The early CT group had a significantly shorter hospitalization length compared with the late CT group (15.0 days vs. 20.5 days; P = 0.035). Besides, the median time to initiate drainage after admission was also significantly shorter in the early CT group than in the late CT group (1.0 days vs. 4.5 days; P < 0.001).

Conclusion

Early CT scanning within 48 h of admission may aid in early PLA diagnosis and benefit disease recovery, as revealed by our findings.

Double pigtail tube drainage for large multiloculated pyogenic liver abscesses

Background

This study aims to investigate the efficacy and safety of double pigtail tube drainage compared with single pigtail tube drainage for the treatment of multiloculated pyogenic liver abscesses greater than 5 cm.

Patients and Methods

This study retrospectively analyzed patients with pyogenic liver abscess admitted in the Affiliated Hospital of Chengde Medical College between May 2013 and May 2021. Patients with pyogenic liver abscess more than 5 cm in size, who underwent drainage of the abscess with either double pigtail or single pigtail tube, were included.

Results

A total of 97 patients with pyogenic liver abscesses larger than 5 cm were studied. These included 34 patients with double pigtail tube drainage and 63 patients with single pigtail tube drainage. The postoperative hospital stay (13.39 ± 4.21 days vs. 15.67 ± 7.50 days; P = 0.045), and time for removal of the catheter (17.23 ± 3.70 days vs. 24.11 ± 5.83 days; P = 0.038) were lower in the double pigtail tube group compared with the single pigtail tube group. The rate of reduction, in three days, of c-reactive protein levels was 26.61 ± 14.11 mg/L/day in the double pigtail tube group vs. 20.06 ± 11.74 mg/L/day in the single pigtail tube group (P = 0.025). The diameter of the abscess cavity at discharge was 3.1 ± 0.07 cm in the double pigtail tube group as compared with 3.7 ± 0.6 cm in the single pigtail tube group (P = 0.047). There was no bleeding in any of the patients despite abnormal coagulation profiles. There was no recurrence of abscess within six months of discharge and no death in the double pigtail tube group. Conclusion: Double pigtail tube drainage treatment in multiloculated pyogenic liver abscesses greater than 5 cm in size, is safe and effective.

Prognostic value of platelet count-related ratios on admission in patients with pyogenic liver abscess

OBJECTIVE

The purpose of the current study was to evaluate the association between C-reactive protein-to-platelet ratio (CPR), neutrophil-to-lymphocyte*platelet ratio (NLPR) and fibrinogen-to-platelet ratio (FPR) and the prognoses of pyogenic liver abscess (PLA) patients.

METHODS

A cohort of 372 patients with confirmed PLA were enrolled in this retrospective study between 2015 and 2021. Laboratory data were collected on admission within 24 h. The demographic characteristics and clinical features were recorded. Risk factors for outcomes of PLA patients were determined via multivariate logistic regression analyses, and optimal cut-off values were estimated by using the receiver operating characteristic (ROC) curve analysis.

RESULTS

Out of 372 patients, 57.8% were men, 80 (21.5%) developed sepsis, and 33 (8.9%) developed septic shock. The levels of CPR, NLPR and FPR were significantly increased in the development of sepsis, and prolonged hospital stays in PLA patients. The multivariate logistic regression analysis indicated that the CPR (OR: 2.262, 95% CI: 1.586-3.226, p < 0.001), NLPR (OR: 1.118, 95% CI: 1.070-1.167, p < 0.001) and FPR (OR: 1.197, 95% CI: 1.079-1.329, p = 0.001) were independent risks of PLA patients with sepsis, and NLPR (OR: 1.019, 95% CI: 1.004-1.046, p = 0.019) was shown to be an independent predictor of prolonged hospital stays. The ROC curve results showed that the three biomarkers had different predictive values, and CPR proved to work best, with a ROC value of 0.851 (95% CI: 0.807-0.896, p < 0.001) for sepsis.

CONCLUSION

Higher levels of CPR, NLPR and FPR were associated with a higher risk of poor outcomes. Moreover, a high CPR level performed best when predicting the clinical outcome in PLA patients.

Efficacy and Prognosis of Ultrasound-Guided Percutaneous Catheter Drainage in Patients with Liver Abscess Complicated with Septic Shock

Objective

Currently, the therapeutic effect and outcomes of US-PCD in patients with liver abscess and septic shock remain unclear. This study is aimed at investigating the effects of ultrasound-guided percutaneous catheter drainage (US-PCD) on the prognosis of patients with liver abscess complicated with septic shock.

Method

We retrieved and assessed the data of 120 patients with liver abscess complicated with septic shock diagnosed at our hospital from January 2019 to March 2021. The patients underwent US-PCD in the observation group or conventional surgical incision and drainage in the control group. After treatment, we determined the levels of liver function indicators alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL), and alkaline phosphatase (ALP) as well as the levels of inflammatory cytokines IL-6, IL-8, and TNF-α in serum using ELISA on postoperative days 0, 2, 4, and 6. The postoperative body temperature recovery, peripheral white blood cell count recovery, extubation, postoperative length of stay, and complications were recorded, with a 12-month follow-up to calculate their survival rate.

Results

After treatment, the ALT, AST, TBIL, DBIL, and ALP levels and inflammatory factor levels in the two groups were gradually reduced over time and returned to the normal range with a better recovery trend in the observation group. US-PCD was associated with better postoperative body temperature recovery, peripheral white blood cell count recovery, shorter extubation time, hospital stay, lower postoperative rate, and a higher survival rate.

Conclusion

US-PCD may be effective in treating liver abscess and can significantly improve the prognosis of patients.

Clinical features and development of Sepsis in Klebsiella pneumoniae infected liver abscess patients: a retrospective analysis of 135 cases

Background

Klebsiella pneumoniae is a primary pathogen of pyogenic liver abscess (PLA). However, little data are available on combination with sepsis. In this study, we aimed to evaluate the clinical characteristics and prognostic differences of PLA patients with sepsis.

Methods

This retrospective cohort study was conducted to investigate 135 patients with confirmed Klebsiella pneumoniae-caused liver abscesses (KPLA) from a tertiary teaching hospital, from 2013 to 2019. The patients were divided into two groups, KPLA with sepsis and KPLA without sepsis. The demographic characteristics, clinical features as well as laboratory and microbiologic findings were analyzed.

Results

A total of 135 patients with KPLA were analyzed. The mean age of patients was 60.9 ± 12.7 years, and the percentage of men was 59.3%. Among them, 37/135 (27.4%) of patients had sepsis and the mortality rate was 1.5%. The most common symptom was fever (91.1%). KPLA patients with sepsis had a significantly higher proportion of frailty, diarrhea, fatty liver, chronic renal insufficiency, and hepatic dysfunction compared to KPLA patients without sepsis (p < 0.05). Antibiotic therapy and percutaneous drainage were most frequently therapeutic strategy. Furthermore, the incidences of sepsis shock and acute respiratory distress syndrome were higher in the sepsis group compared to the non-sepsis group. As for metastatic infections, the lung was the most common site. In addition, KPLA patients with sepsis showed respiratory symptoms in 11 patients, endophthalmitis in 4 patients, and meningitis in 1 patient.

Conclusion

Our findings emphasize that KPLA patients combined with or without sepsis have different clinical features, but KPLA patients with sepsis have higher rates of complications and metastatic infections. Taken together, further surveillance and control of septic spread is essential for KPLA patients.

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.

The Delta Neutrophil Index Predicts the Development of In-hospital Hypotension in Initially Stable Patients with Pyogenic Liver Abscess

Prompt diagnosis and timely treatment are important for reducing morbidity and mortality from pyogenic liver abscess (PLA). The purpose of this study was to investigate the importance of the delta neutrophil index (DNI) reflecting the fraction of immature granulocytes as a predictor of the development of in-hospital hypotension in initially stable patients with PLA. We retrospectively identified 308 consecutive patients (>18 years) who were hemodynamically stable at presentation and diagnosed with PLA in the emergency department (ED) between January 2011 and September 2017. The outcome of interest was in-hospital hypotension 1–24 hours after admission to the ED. A high DNI at ED admission was an independent predictor of the development of in-hospital hypotension in initially stable patients with PLA (odds ratio [OR]: 1.44, 95.0% confidence interval [CI]: 1.06–1.95; P = 0.02). A DNI > 3.3% was associated with in-hospital hypotension at ED admission (OR: 5.37, 95.0% CI: 2.91–9.92; P < 0.001). The development of in-hospital hypotension was associated with an increased risk of 30-day mortality (HR: 8.55, 95.0% CI: 2.57–28.4; P < 0.001). A high DNI independently predicts the development of in-hospital hypotension in initially stable patients with PLA. In-hospital hypotension is associated with an increased risk of 30-day mortality.

Neutrophil-to-lymphocyte ratio as a feasible prognostic marker for pyogenic liver abscess in the emergency department

PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) is an effective predictor of mortality in patients with for various conditions. To date, there are no previous studies on NLR as a prognostic marker for pyogenic liver abscess (PLA), especially on admission to the emergency department (ED).

METHODS

From January 2013 to December 2015, 102 patients diagnosed with PLA in the ED were included. Clinico-radiological and laboratory results, including NLR, were evaluated as variables. NLR was calculated as absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of PLA, data on hospital mortality, intensive care unit (ICU) admission, and development of septic shock were obtained. Multivariate logistic regression analyses and receiver-operating characteristic (ROC) curve analysis were performed.

RESULTS

Among 102 patients, 10 (9.8%) died, 14 (13.7%) were admitted to the ICU, and 15 (14.7%) developed septic shock during hospitalization. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting death [odds ratio (OR), 1.4; p = 0.020], ICU admission (OR, 1.4; p = 0.021), and development of septic shock (OR, 1.6; p = 0.041). NLR showed an excellent predictive performance for death (areas under the ROC curves [AUC], 0.941; cut-off value, 19.7; p < 0.001), ICU admission (AUC, 0.946; cut-off value, 16.9; p < 0.001), and development of septic shock (AUC, 0.927; cut-off value, 16.9; p < 0.001).

CONCLUSION

NLR was positively associated with poor prognosis of PLA; elevated NLR could predictor of high risk of death, ICU admission, and development of septic shock. Emergency physicians should consider NLR for the prognosis of PLA and early aggressive treatment, especially in patients with NLR > 16.9.