Aging is Associated with Prolonged Hospitalisation Stay in Pyogenic Liver Abscess-A 1:1 Propensity Score Matched Study in Elderly Versus Non-Elderly Patients

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.

Can propensity score matching replace randomized controlled trials?

Randomized controlled trials (RCTs) have long been recognized as the gold standard for establishing causal relationships in clinical research. Despite that, various limitations of RCTs prevent its widespread implementation, ranging from the ethicality of withholding potentially-lifesaving treatment from a group to relatively poor external validity due to stringent inclusion criteria, amongst others. However, with the introduction of propensity score matching (PSM) as a retrospective statistical tool, new frontiers in establishing causation in clinical research were opened up. PSM predicts treatment effects using observational data from existing sources such as registries or electronic health records, to create a matched sample of participants who received or did not receive the intervention based on their propensity scores, which takes into account characteristics such as age, gender and comorbidities. Given its retrospective nature and its use of observational data from existing sources, PSM circumvents the aforementioned ethical issues faced by RCTs. Majority of RCTs exclude elderly, pregnant women and young children; thus, evidence of therapy efficacy is rarely proven by robust clinical research for this population. On the other hand, by matching study patient characteristics to that of the population of interest, including the elderly, pregnant women and young children, PSM allows for generalization of results to the wider population and hence greatly increases the external validity. Instead of replacing RCTs with PSM, the synergistic integration of PSM into RCTs stands to provide better research outcomes with both methods complementing each other. For example, in an RCT investigating the impact of mannitol on outcomes among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial, the baseline characteristics of comorbidities and current medications between treatment and control arms were significantly different despite the randomization protocol. Therefore, PSM was incorporated in its analysis to create samples from the treatment and control arms that were matched in terms of these baseline characteristics, thus providing a fairer comparison for the impact of mannitol. This literature review reports the applications, advantages, and considerations of using PSM with RCTs, illustrating its utility in refining randomization, improving external validity, and accounting for non-compliance to protocol. Future research should consider integrating the use of PSM in RCTs to better generalize outcomes to target populations for clinical practice and thereby benefit a wider range of patients, while maintaining the robustness of randomization offered by RCTs.

Sarcopenia as an important determinant for adverse outcomes in patients with pyogenic liver abscess

Background

Low muscle mass/sarcopenia has been associated with poor prognosis in many diseases, but its clinical significance in pyogenic liver abscess (PLA) remains unclear. The purpose of this study is to investigate the relationship between muscle mass and prognosis of patients with PLA.

Methods

A total of 154 adult patients with PLA hospitalized at Tongji Hospital (Wuhan, Hubei, China) between October 2011 and June 2021 were included in this retrospective analysis. Muscle-fat related indicators were measured by computed tomography (CT) images at the third lumbar vertebra (L3) level. The data of patients between the sarcopenia group and non-sarcopenia group were compared. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were performed.

Results

The skeletal muscle index (SMI) was independently associated with adverse outcomes (95% CI [0.649-0.954], P = 0.015) of PLA in multivariate logistic regression analysis. This conclusion held true in sex-specific subgroup analysis. ROC analysis indicated that SMI may predict adverse outcomes in both male (area under the ROC curve [AUC], 0.718; cut-off, 52.59; P < 0.001) and female (AUC, 0.714; cut-off, 38.39; P = 0.017) patient populations.

Conclusions

Sarcopenia serves as an independent risk factor for poor prognosis in PLA and patients with sarcopenia may be more prone to adverse outcomes.

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.

Demographics and Clinical Outcomes of Culture-Positive versus Culture-Negative Pyogenic Liver Abscess in an Asian Population

Objective

Despite its high case-fatality risk, pyogenic liver abscess (PLA) lacks clear management guidelines in patients with negative microbial cultures. Our aim was to evaluate differences in clinical characteristics between patients with culture-negative liver abscess (CNLA) and those with culture-positive liver abscess (CPLA), and identify differences in the main causative pathogen.

Methods

In this study, we retrospectively collected medical records of PLA patients admitted to a teaching hospital from January 2010 to December 2019.

Results

In total, 324 PLA patients were enrolled in this study. Of these, 202 (62.3%) cases were confirmed cultural positive, including 109 patients (54%) and 20 (9.9%) patients infected with Klebsiella pneumoniae (K. pneumoniae) and Escherichia coli (E.coli), respectively. Patients in the CPLA group were older (p=0.029) and had higher prevalence of abscesses larger than 5 cm in diameter (p = 0.003), gas-forming rate (p = 0.016), and percutaneous drainage (p < 0.001) compared with CNLA group. Patients with CPLA had significantly longer hospitalizations than those with CNLA (p = 0.010). Nevertheless, there was no significant difference in in-hospital mortality between the two groups (p = 0.415). Compared with patients with E. coli, those with K. pneumoniae had higher incidence of diabetes mellitus (p = 0.041), solitary abscess (p < 0.001), localization in the right hepatic lobe (p = 0.033), abscess size larger than 5 cm (p < 0.001) and percutaneous drainage (p = 0.002), but mortality was not significantly different (p = 1.000).

Conclusion

No significant difference in in-hospital mortality was found between patients with CNLA and those with CPLA group. However, clinical characteristics and management were different between the main causative pathogens, including K. pneumoniae and E. coli.

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.