Invasive liver abscess syndrome caused by Klebsiella pneumoniae

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Invasive liver abscess syndrome caused by
Klebsiella pneumoniae
September 17, 2007

• Wen-Liang Yu, MD
• Yin-Ching Chuang, MD

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INTRODUCTION

• Klebsiella pneumoniae patients with impaired
  host defenses (eg, DM, alcoholism, malignancy,
  COPD, glucocorticoid therapy).
• Associated with Community-acquired primary
  invasive liver abscess syndrome (Liver abscess
  Metastatic infection)

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DEFINITION

• Primary liver abscess a K. pneumoniae liver
  abscess (KLA)occurring in the absence of
  predisposing intraabdominal factors, such as
  hepatobiliary disease, colorectal disease, or a
  history of intraabdominal surgery or trauma, or
  as a monomicrobial K. pneumoniae isolate
• Polymicrobial liver abscess was usually secondary
  to hepatobiliary disease or intraabdominal
  infection

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EPIDEMIOLOGY

• KLA, particularly those associated with
  metastatic infection, have been reported in
  Taiwan and are community-acquired
• 171 KP / 248 pyogenic liver abscess (69)
• Community-acquired primary liver abscess Other
  countries in Asia, in Asian patients living in
  other countries , in South Africa , and, less
  often, in non-Asian patients in the United
  States, particularly Hispanics, and in Europe and
  Canada

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EPIDEMIOLOGY

• New York, 79 cases of liver abscess
• KP the most common identified pathogen, being
  isolated from 23 of 54 (43) liver abscesses in
  which an organism was recovered.
• K. pneumoniae was more commonly isolated among
  Asian patients than non-Asian patients (50 versus
  27 percent). However, 43 percent of patients in
  this series had underlying hepatobiliary disease,
  not primary liver abscess
• Metastatic infection (Taiwan) endophthalmitis
  and/or meningitis

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PATHOGENESIS AND RISK FACTORS

• Klebsiella primary liver abscess (KLA) frequently
  occurs in patients with diabetes, but can occur
  in the absence of underlying predisposing medical
  conditions.

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Virulence factors

• Regional differences of K. pneumoniae liver
  abscess (KLA) 455 consecutive cases of KP
  bacteremia in 7 countries (Taiwan, South Africa,
  United States, Australia, Belgium, Turkey, and
  Argentina) .
• The invasive community-acquired syndrome of liver
  abscess, meningitis, or endophthalmitis was only
  seen in Taiwan and South Africa. - geographic
  restriction -

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Virulence factors

• (Taiwan South Africa) compared to the other
  countries
• -- mucoid phenotype (100 vs 2 ) and to be
  rmpA-positive (86 vs 7 )
• -- K1 capsular serotype

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Host factors

• Risk factor for primary KLA
• DM 70 78
• ?Poor glycemic control impairs neutrophil
  phagocytosis of K1 and K2 capsular serotypes
• High prevalence of DM with KLA is not seen with
  other causes of liver abscess (eg, 75 vs 5 with
  polymicrobial liver abscess, and 70 vs 33 with
  non-KP liver abscess)

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CLINICAL MANIFESTATIONS

• 160 cases from Taiwan
• Fever (93)
• RUQ tenderness (71)
• Nausea, vomiting, diarrhea, or abdominal pain
  (38)
• Leukocytosis (70)
• Elevations in GOT,GPT (59 and 68)
• Alkaline phosphatase (78)
• Bilirubin (26)

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CLINICAL MANIFESTATIONS

• In contrast to liver abscesses caused by other
  organisms, those due to KP are more likely to be
  solitary and more likely to be monomicrobial .
• In a report from Taiwan, for example, 65 of 68
  were monomicrobial.

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Metastatic infection

• A minority of patients with primary liver abscess
  develop metastatic infection at other sites
• Manifestations endophthalmitis, meningitis and
  brain abscess.
• Other lumbar or cervical spondylitis and
  diskitis, septic pulmonary emboli, lung abscess,
  psoas abscess, splenic abscess, necrotizing
  fasciitis, neck abscess, and osteomyelitis

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Metastatic infection

• Incidence in Taiwan Metastatic infection
  occurred in 23 of 177 patients (13) and 19 of
  160 patients (11.9) with KLA, and metastatic
  infection in patients with pyogenic liver abscess
  was more common with KP than with other bacterial
  isolates (14.6 vs 3.8 ).
• A somewhat lower rate of metastatic infection
  (8.7) was noted in a series of 290 patients with
  KLA from Korea

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Metastatic infectionin US

• No cases of metastatic infection among the 23
  patients with KLA in a study from New York ,
  while a review of 18 cases in the US prior to the
  New York study found metastatic infection in five
  (28 percent)

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Metastatic infection

• In the study in which metastatic infection
  occurred in 23 of 177 patients with pyogenic
  liver abscess
• 53 primary infections
• 76 secondary infections
• 48 unclassified infections

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• Secondary infection was defined as liver abscess
  in patients with hepatobiliary disease or other
  intraabdominal factors, such as colorectal
  disease or a history of intraabdominal surgery or
  trauma.
• Metastatic infection occurred in 22 of 121
  patients with primary liver abscess and 1 of 56
  with secondary liver abscess (18 vs 2)

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• In the study in which metastatic infection
  occurred in 19 of 160 patients with primary liver
  abscess, there were no cases of metastatic
  infection in 22 patients with polymicrobial
  secondary liver abscess

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• Risk factors
• ? the more virulent K1 serotype
• Taiwan patients with KLA septic endophthalmitis
  was present in infections with 12 of 85 K1
  strains, 2 of 19 K2 strains, and none of 28
  non-K1/K2 strains
• ? Presence of the magA gene (kfu iron-uptake
  system )

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DIAGNOSIS AND TREATMENT

• Ultrasonography and computed tomography (CT)
• KP bacteremia and persistent fever despite
  appropriate antibiotic therapy

A contrast-enhanced CT scan of the upper abdomen
demonstrates a large gas-containing abscess in
the right lobe of the liver. This location is
easily amenable to percutaneous CT-guided drainage
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• On ultrasonography, KP liver abscesses often have
  a predominantly solid appearance and, compared to
  other causes of bacterial liver abscess, have a
  much smaller quantity of pus at initial
  aspiration
• ? diagnostic aspiration ? Gram stain and both
  aerobic and anaerobic culture B/C ? Echo- or
  CT-guided drainage

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Antibiotic therapy

• Community-acquired KLA isolates rarely produce
  extended-spectrum beta-lactamases (ESBL)

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• Reports from Taiwan and Korea
• ?ESBL and cephalosporins with or without
  aminoglycosides (less severe cases) ?Higher
  metastatic infection rates among patients treated
  with cefazolin compared to those treated with a
  second or third generation cephalosporin, both
  with or without an aminoglycoside (37 vs 6 )

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• Aminoglycosides penetrate abscess cavities
  poorly toxicity gt benefit
• Abx duration 4 6 wks (longer if required
  drainage or CT proof)
• Iv form 2-3 wks then oral form
• Image F/U

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PROGNOSIS

• Studies from Taiwan review of 160 cases of KLA
  (all but one primary) ? mortality rate was 11.3
  and relapse occurred in 4.4
• 18 pt death
• - 9 fulminant sepsis
• - 4 metastatic infection(2 meningitis, 1 brain
  abscess, 1 lung abscess, 1 necrotizing fasciitis)
• - 2 ruptured abscess

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• Higher mortality rate (41) in 22 patients with
  polymicrobial liver abscess ? Sepsis (the only
  cause)
• Other study 248 patients with pyogenic liver
  abscess (171 due to K. pneumoniae and 77 to other
  bacteria)
• Mortality rate was significantly lower in
  patients with KP infection (4.1 vs 20.8 ), while
  the relapse rate was the same in the two groups
  (6.5 vs 6.4 )

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• Pts with metastatic endophthalmitis Mortality
  low, but prognosis poor ? Blindness
• Pts with meningitis ? persistent neurologic
  abnormalities
• A report of 23 pts with KLA(metastatic infection
  involving the eye or central nervous system)
• 16 severe irreversible disability loss of
  vision, quadriplegia, paraparesis, or impaired
  higher cortical function

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Thanks for your attention