肺炎克雷伯杆菌性肝脓肿[材料浅析]
肺炎克雷伯杆菌性肝脓肿
该病的发病率较低，但病情严重，病死率高，需引起重视。
02
临床表现与诊断
症状
寒战
畏寒、寒战，常见 于大叶性肺炎。
胸痛
胸痛明显，深呼吸 或咳嗽时加重。
发热
持续高热，体温可 高达39℃以上，呈 弛张热或稽留热型。
咳嗽
咳嗽频繁，痰量多， 呈脓性或黏液脓性。
呼吸困难
呼吸急促、困难， 严重时可出现发绀。
体征
肺部体征
肺部可闻及湿啰音，病变广泛时可出现管状 呼吸音。
肝脏肿大
肝脏肿大、压痛，肝区叩击痛阳性。
其他体征
部分患者可出现黄疸、脾大、腹腔积液等。
诊断标准与鉴别诊断
诊断标准
根据临床表现、实验室检查和影像学检查进行综合诊断。
鉴别诊断
需与其他原因引起的肝脓肿、肺部感染等疾病相鉴别。
03
治疗方法
药物治疗
其他治疗方法
支持治疗
对于病情较重、身体虚弱的患者，可采用支 持治疗方法，如营养支持、免疫支持等，以 提高身体抵抗力，促进康复。
中医治疗
根据中医理论，采用中药方剂或针灸等方法 进行治疗，以调理身体、缓解症状。
04
预防与预后
预防措施
01
02
03
04
提高免疫力
保持健康的生活方式，包括均 衡饮食、适量运动和充足的休
并发症
治疗不及时或不当可能导致并发症，如脓毒 血症、感染性休克等。
死亡率
在严重病例中，肺炎克雷伯杆菌性肝脓肿可 能导致死亡，但死亡病例相对较少。
康复与护理
休息与活动
患者需要充分休息，遵医嘱进 行活动和康复训练。
药物治疗
按照医生的建议使用抗生素和 其他药物，确保足量、足疗程 的治疗。
肝脓肿肺炎克雷伯菌血清分型及毒力基因研究
肝脓肿肺炎克雷伯菌血清分型及毒力基因研究李花;王倩【摘要】目的探讨肝脓肿相关肺炎克雷伯菌耐药性、血清型和毒力基因分布.方法收集75株肝脓肿患者临床分离肺炎克雷伯菌,采用Vitek2系统检测耐药性;PCR法检测血清型及毒力基因分布情况.结果 75株肝脓肿肺炎克雷伯菌对哌拉西林耐药率为16％,对复方磺胺甲噁唑的耐药率为4％,对头孢菌素类、氨基糖苷类等多种抗菌药物敏感.血清型分布以K1型(62.7％)为主,其次为K2型(21.3％),其他型别K5、K20、K54及K57均占2.7％,4株(5.3％)未分型.毒力基因以rmpA和aer-obactin检出率最高,分别达98.7％和97.3％,其次为kfu(68％)、wcaG(66.7％)和allS(57.3％).K1血清型菌株中以rmpA、wcaG、aerobactin、kfu和allS 5种毒力基因同时携带为主,占83％;K2、K20和K57型菌株的主要携带模式为rmpA+aerobactin;K5型为rmpA+aerobactin+kfu;K54型为rmpA+aerobactin+wcaG.结论肝脓肿相关肺炎克雷伯菌对多种抗菌药物敏感,K1、K2型是主要血清型,毒力基因rmpA和aerobactin检出率最高,K1血清型毒力基因检出种类最多.【期刊名称】《临床检验杂志》【年(卷),期】2018(036)007【总页数】3页(P493-495)【关键词】肺炎克雷伯菌;肝脓肿;血清型;毒力基因【作者】李花;王倩【作者单位】中国医科大学附属第一医院检验科,沈阳 110001;中国医科大学附属第一医院检验科,沈阳 110001【正文语种】中文【中图分类】R446.5近年来，关于肺炎克雷伯菌(Klebsiella pneumonia)所致的原发性肝脓肿的报道显著增多[1]。
我国研究显示，肺炎克雷伯菌相关肝脓肿占化脓性肝脓肿的60%～70%[2]。
引起肝脓肿的肺炎克雷伯菌多为高黏液表型的高毒力菌株，其毒力与荚膜血清分型及与黏液表型、铁摄入系统等相关的毒力基因关系密切。
肺炎克雷伯菌所致肝脓肿患者的临床特征及毒力基因检测
１．１ 研 究 对 象 研 究 对 象 为 江 苏 大 学 附 属 医 院 ２０１７年７月—２０１９年８ 月 收 治 的 ３４ 例 细 菌 性 肝 脓 肿 患 者 。 所 有 患 者 均 符 合 以 下 诊 断 标 准［５］：① 具 有 发 热、寒 战 或 腹 痛 等 临 床症 状 ；② 影 像 学 检 查 结 果 （Ｂ 超 或 ＣＴ）符合 肝脓 肿影 像 学特 征；③ 血 培 养 或 脓 液 培 养 出 致 病 菌 ；④ 经 皮 肝 穿 刺 或 外 科 手 术 治 疗 后 证 实 ； ⑤ 排 除 阿 米 巴 、结 核 性 肝 脓 肿 。 根 据 细 菌 培 养 结 果 将 细菌 性 肝 脓 肿 患 者 分 为 肺 炎 克 雷 伯 菌 肝 脓 肿 组 （ＫＰ ＬＡ 组）与非肺炎克雷伯菌肝脓肿组（ＮＫＰＬＡ 组）。 １．２ 方 法 １．２．１ 研究方法 通 过 查 阅 患 者 病 历，对 ３４ 例 细 菌性肝脓肿患者的 临 床 资 料、实 验 室 资 料 和 影 像 学 资料进行 回 顾 性 分 析。 对 从 上 述 患 者 体 内 分 离 的 ２２株肺炎克 雷 伯 菌 进 行 药 敏 试 验、耐 药 基 因 检 测、 黏 液 丝 试 验 、荚 膜 血 清 分 型 及 毒 力 基 因 检 测 。 １．２．２ 主 要 仪 器 及 试 剂 ＶＩＴＥＫ２Ｃｏｍｐａｃｔ全 自
· ６２０ ·
中 国 感 Байду номын сангаас 控 制 杂 志 ２０２１ 年 ７ 月 第 ２０ 卷 第 ７ 期 ＣｈｉｎＪＩｎｆｅｃｔＣｏｎｔｒｏｌＶｏｌ２０ Ｎｏ７Ｊｕｌ２０２１
ｐｎｅｕｍｏｎｉａｅ （ｈｖＫＰ），５ｋｉｎｄｓｏｆｈｙｐｅｒｖｉｒｕｌｅｎｔｃａｐｓｕｌａｒｓｅｒｏｔｙｐｅｓｗｅｒｅｄｅｔｅｃｔｅｄ，ａｎｄ Ｋ１ ｗａｓｔｈｅ ｍａｉｎｓｅｒｏｔｙｐｅ， ａｃｃｏｕｎｔｉｎｇｆｏｒ６８．２％ ．２２ｓｔｒａｉｎｓｏｆＫＰａｌｌｃａｒｒｉｅｄｖｉｒｕｌｅｎｃｅｇｅｎｅｓ狉犿狆Ａ，犻狌犮Ａ，犻狉狅Ｂａｎｄ犻狌狋Ａ．犆狅狀犮犾狌狊犻狅狀 ＫＰＬＡ ｉｓｍｏｒｅｃｏｍｍｏｎｉｎ ｍｉｄｄｌｅａｇｅｄａｎｄｏｌｄ ｍｅｎ，ｍｏｓｔａｒｅ ｗｉｔｈｕｎｄｅｒｌｙｉｎｇｄｉｓｅａｓｅｄｉａｂｅｔｅｓ ｍｅｌｌｉｔｕｓ，ａｌｌｓｔｒａｉｎｓａｒｅ ｈｖＫＰ，ｍａｉｎｌｙＫ１ｓｅｒｏｔｙｐｅ，ａｎｄｃａｒｒｙａｌａｒｇｅｎｕｍｂｅｒｏｆｖｉｒｕｌｅｎｃｅｇｅｎｅｓ，ｒｅｓｉｓｔａｎｃｅｒａｔｅｔｏｃｏｍｍｏｎｌｙｕｓｅｄａｎｔｉｍｉ ｃｒｏｂｉａｌａｇｅｎｔｓｉｓｌｏｗ，ｂｕｔｉｔｃａｎｃａｒｒｙｒｅｓｉｓｔａｎｃｅｇｅｎｅｓ，ｗｈｉｃｈｎｅｅｄｓｔｏｂｅｐａｉｄｇｒｅａｔａｔｔｅｎｔｉｏｎｂｙｃｌｉｎｉｃｉａｎｓ． ［犓犲狔狑狅狉犱狊］ 犓犾犲犫狊犻犲犾犾犪狆狀犲狌犿狅狀犻犪犲；ｌｉｖｅｒａｂｓｃｅｓｓ；ｃｌｉｎｉｃａｌｃｈａｒａｃｔｅｒｉｓｔｉｃ；ｖｉｒｕｌｅｎｃｅｇｅｎｅ
肺炎克雷伯杆菌性肝脓肿
a
10
肺炎克雷伯氏杆菌引起的气 性肝脓肿
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34.38±3.25
穿刺后体温 平稳天数
5.79±1.24
6.75±1.72
a
13
治疗方面
使用二联抗生素或三联抗生素（甲硝唑/奥硝唑，喹诺酮类，二、 三代头孢）
分别比较了仅穿刺组、穿刺+冲洗组、穿刺+置管组均发现使用二联 抗生素及三联抗生素无明显差异
a
14
复旦大学附属医院消化科（2010临床肝胆病杂 志）
29.54±3.17
4.35±0.64
a
12
治疗方面
穿刺后是否置管
单独穿刺 （n=24）
白细胞计数 降低
0.71
穿刺+置管 （n=24）
7.68±1.09
穿刺后一周B超显示脓肿减少更明 显
中性粒细胞 百分比降低
17.72±0.41
15.20±2.18
穿刺后脓肿 缩小范围
22.67±2.37
引起肝脓肿的肺炎克雷伯菌以高粘液性菌株为主，共90株，占所有 101例分离株的89.11%，其中血清型K1检出率为95%（41/43），血 清型K2检出率为92%（34/37），K1和K2组高粘液性表型相对较高。
a
5
12年中山医院
KLA
伴发基础疾病 临床表现
实验室检查 影像学检查
侵袭性肺炎克雷伯菌肝脓肿综合征患者临床特征分析
【临床研究】
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侵袭性肺炎克雷伯菌肝脓肿综合征患者临床特征分析
郭新珍
（中日友好医院感染疾病科，北京 １０００２１）
摘要： 目的 分析侵袭性肺炎克雷伯菌肝脓肿综合征患者的临床特征。方法 回顾性分析 ２０１０年 １月至 ２０１７ 年 １０月中日友好医院收治的资料完整的确诊为肺炎克雷伯菌肝脓肿患者的临床资料。结果 符合侵袭性肺炎克雷 伯菌肝脓肿综合征患者 ９例，男 ６例，女 ３例，年龄（５６．７７±１０．２８）岁。并发糖尿病 ４例，糖耐量异常 １例，胆石症、慢 性胆囊炎 ２例。单发脓肿 ７例，多发脓肿 ２例；血培养阳性 ８例。受累部位：肺部 ７例，眼部 ３例，皮肤软组织 １例，关 节 １例，神经系统 １例。血白细胞计数升高 ８例，丙氨酸氨基转移酶水平升高 ９例，降钙素原水平升高 ７例，肺炎克雷 伯菌产超广谱 β内酰胺酶阳性 １例。３例眼内炎患者均失明，１例并发脑膜炎患者死亡。结论 侵袭性肺炎克雷伯菌 肝脓肿综合征常见于糖尿病人群，可伴机体多部位的转移感染灶，肺部为常见受累器官。
（ＩＫＬＡＳ）．Ｍｅｔｈｏｄｓ ＴｈｅｃｌｉｎｉｃａｌｄａｔａｏｆＩＫＬＡＳｐａｔｉｅｎｔｓｄｉａｇｎｏｓｅｄｉｎＣｈｉｎａＪａｐａｎＦｒｉｅｎｄｓｈｉｐｈｏｓｐｉｔａｌｆｒｏｍＪａｎｕａｒｙ２０１０ｔｏ Ｏｃｔｏｂｅｒ２０１７ｗａｓａｎａｌｙｚｅｄｒｅｔｒｏｓｐｅｃｔｉｖｅｌｙ．Ｒｅｓｕｌｔｓ Ｔｈｅｒｅｗｅｒｅ９ｐａｔｉｅｎｔｓｗｉｔｈＩＫＬＡＳｉｎｃｌｕｄｉｎｇ６ｍａｌｅｓａｎｄ３ｆｅｍａｌｅｓａｇｅｄ （５６．７７±１０．２８）ｙｅａｒｓｏｌｄ．Ｆｏｕｒｃａｓｅｓｗｉｔｈｄｉａｂｅｔｅｓｍｅｌｌｉｔｕｓ，ｏｎｅｃａｓｅｗｉｔｈｉｍｐａｉｒｅｄｇｌｕｃｏｓｅｔｏｌｅｒａｎｃｅ，ａｎｄｔｗｏｃａｓｅｓｗｉｔｈ ｃｈｏｌｅｌｉｔｈｉａｓｉｓｈｉｓｔｏｒｙ．Ｓｉｎｇｌｅａｂｓｃｅｓｓ（７／９），ｍｕｌｔｉｐｌｅａｂｓｃｅｓｓ（２／９）．Ｉｎｖｏｌｖｅｄｏｒｇａｎｓ：ｌｕｎｇ（７／９），ｅｙｅｓ（３／９），ｓｏｆｔｔｉｓｓｕｅ （１／９），ｊｏｉｎｔ（１／９）ａｎｄｎｅｒｖｅｓｙｓｔｅｍ（１／９）．Ｌａｂｏｒａｔｏｒｙｔｅｓｔｓｈｏｗｅｄａｎｅｌｅｖａｔｉｏｎｏｆｔｈｅｗｈｉｔｅｂｌｏｏｄｃｅｌｌｃｏｕｎｔ（８／９）ＰＣＴ（７／９），ａｎｄｏｎｌｙｏｎｅＥＳＢＬｐｏｓｉｔｉｖｅＫｌｅｂｓｉｅｌｌａｐｎｅｕｍｏｎｉａ．Ｔｈｒｅｅｃａｓｅｓｗｉｔｈｅｎ ｄｏｐｈｔｈａｌｍｉｔｉｓｌｏｓｔｔｈｅｉｒｓｉｇｈｔ，ａｎｄｏｎｅｗｉｔｈｍｅｎｉｎｇｉｔｉｓｄｉｅｄ．Ｃｏｎｃｌｕｓｉｏｎ ＩＫＬＡＳｉｓｃｏｍｍｏｎｉｎｐｅｏｐｌｅｗｉｔｈｄｉａｂｅｔｅｓ，ａｎｄｉｔ ｍａｙｂｅａｓｓｏｃｉａｔｅｄｗｉｔｈｍｕｌｔｉｐｌｅｓｉｔｅｓｏｆｍｅｔａｓｔａｓｉｓｏｆｔｈｅｂｏｄｙａｎｄｌｕｎｇｓａｒｅｔｈｅｍｏｓｔｉｎｖｏｌｖｅｄｏｒｇａｎ．
糖尿病合并侵袭性肺炎克雷伯菌肝脓肿综合征2例
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1<;+"3$#对哌拉西林他唑巴坦&阿米卡星&亚胺培南西司他丁等药物敏感%图D!肝右叶探及一不均质低回声结节#大小约%4*M7/%4%M 7图E!双侧胸腔可探及液性暗区图F!肝9H段占位#建议增强扫描&腹腔少量积液图I!肝<'段见类圆形稍低密度影&病灶周边肝实质灌注减低!!诊断!$&肺炎克雷伯菌肝脓肿侵袭综合征*!&多脏器功能衰竭*%&感染性休克治疗经过!$&抗休克治疗&给予乳酸钠林格注射液&多巴胺*!&保护肾功能&呋塞米&白蛋白输注*%&纠正酸碱平衡与电解质紊乱&&8碳酸氢钠注射液&枸橼酸钾颗粒*'&改善肝内胆汁淤积&熊去氧胆酸*&&改善微循环与补充血小板&输注右旋糖酐&&新鲜冰冻血浆&补充血小板*(&抗菌治疗&先后给予头孢哌酮钠舒巴坦钠&左氧氟沙星&亚胺培南西司他丁钠&异帕米星治疗*#&高流量鼻导管氧疗*)&彩超引导下肝脓肿穿刺引流术&治疗&周#痊愈康复出院%讨论!近年来#国内相继报道D A引起的肝脓肿逐渐增多#已逐步取代大肠埃希菌成为导致细菌性肝脓肿的主要病原菌'$(*从肝脓肿脓液和)或血液中分离出高毒力D A已引起临床高度关注'!(*国内外相继报道了由D A引起的肝脓肿及其迁徙性感染如菌血症&肺脓肿&眼内炎&坏死性筋膜炎等病例#这种由D A引起肝脓肿及其迁徙性感染的临床症状又称为侵袭性肺炎克雷伯菌肝脓肿综合征"9>'"/&'(D%(G/&(%%",>(L7.>&"(%&'()"G/M(///$>-).7(# 9D+@<$'%3'(*与普通D A不同#引起9D+@<的D A又称为高毒力肺炎克雷伯菌"B$,()'&)L%(>#D%(G/&(%%",>(L7.>&"(&B'D A$#B'D A具有高度侵袭性的临床特征&通常为社区获得性感染#在健康的社区人群中常有发生#9D+@<患者常有糖尿病的基础#这种感染在亚洲环太平洋地区更为普遍#表现为B'D A感染者易发生感染的远处转移&扩散和侵袭#这一特征主要与D A荚膜多糖&铁摄取蛋白及重要的毒力基因有密切关系'&(%本文二例患者在临床上有明显的发热&寒战#且急性起病#感染中毒症状明显#血常规白细胞&中性粒细胞&=2A&A=5均明显升高#全身多脏器受损#感染性休克&血培养或肝脓肿脓液培养培养出D A*根据上述临床特征#本组二例病例细菌感染明确#符合脓毒症&脓毒症休克的诊断标准'((9D+@<最早由台湾地区的学者报道#随后在南亚&北美&欧洲等地区亦陆续被报道#现已成为全球性疾病*本二例患者均有D A肝脓肿及肝外侵袭肺&心&肾&血液系统等多系统损害的+%&!+=E&>(/(B(,"#.%.F$#*(G4!"!!#H.%4!##?.4!表现#血培养或肝脓肿脓液培养出D A#临床表现符合9D+@<诊断*临床研究表明#9D+@<虽在社区人群中发生#糖尿病患者更易发生B'D A肝脓肿并导致侵袭性并发症#且其临床结局与血糖水平显著相关'#(*本文二例患者均长期患有糖尿病#虽经生活方式改变与降糖治疗#但血糖控制不甚理想#导致发生9D+@<的基础*临床上#早期识别糖尿病合并9D+@<至关重要#这对改善其预后尤为重要%国外已有临床研究表明#从临床表现来看#糖尿病合并9D+@<患者更易出现寒战&高热&侵袭性肝外器官#且炎症指标如血常规中的Q;=#=2A&A=5较高#提示糖尿病合并9D+@<的感染征象更为典型#但如临床医师对本病认识不足#也易造成漏诊和)或误诊*糖尿病患者如有发热&寒战&多脏器损害#右上腹隐痛#炎性指标升高#应尽早行血培养&彩色多普勒肝脏超声或腹部=5检查#及时发现肝脓肿#一旦怀疑9D+@<诊断#应尽早给予经验性抗生素治疗#首选碳青霉烯类如美罗培南#亚胺培南#并给予足量*对可疑9D+@<的糖尿病患者应尽早筛查#力争早期诊断#及时治疗%但本文二例均缺少D A 表型"如高黏性表型&血清型等$和基因表型"如特定克隆的菌株等$的临床数据#故研究对象虽符合9D+@<临床诊断#但无B'D A的微生物学诊断证据#这有待后续临床微生物学对糖尿病合并9D+@<的临床特征进行深入探讨%参!考!文!献'$(!S E">F<#S E">F W#Q L T#(#"%4=%&>&M"%#7&M).G&.%.F&M"%#">-7.%(M L%")(,&-(7&.%.F&M"%M E")"M#()&/#&M/.!D%(G/&(%%",>(L7.>&"(3&>-L M(-,$.F(>&M%&'()"G/M(//&>/.L#E("/#()>=E&>"4@>#&7&M).G 2(/&/#9>!(M#=.>#).%#!"$*#)!$((3$#*4'!(!<&L+D#R(E 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American Journal of Gastroenterology ISSN0002-9270 C 2005by Am.Coll.of Gastroenterology doi:10.1111/j.1572-0241.2005.40310.x Published by Blackwell PublishingPyogenic Liver Abscess with a Focus on Klebsiella pneumoniae as a Primary Pathogen:An Emerging Disease with Unique Clinical CharacteristicsEdith R.Lederman,M.D.,and Nancy F.Crum,M.D.,M.P.H.U.S.Naval Medical Research Unit No2,Jakarta,Indonesia;and Naval Medical Center San Diego,San Diego,CaliforniaOBJECTIVES:Pyogenic liver abscess is a common intraabdominal infection.Historically,Escherichia coli(E.coli) has been the predominant causative agent.Klebsiella liver abscess(KLA)wasfirst reported inTaiwan and has surpassed E.coli as the number one isolate from patients with hepatic abscessesin that country and reports from other countries,including the United States,have increased.Weexamined the microbiologic trends of pyogenic liver abscess at our institution to determine if asimilar shift in etiologic agents was occurring.METHODS:We examined all cases of liver abscess at our institution from1999to2003via a retrospective chart review of inpatient records and reviewed the English literature via a MEDLINE search for allU.S.cases of KLA.RESULTS:Since1966,only12cases of KLA have been reported in the United States.We report six cases of KLA at our institution alone;2patients were not Asian,and4were not diabetic.Klebsiellapneumoniae(K.pneumoniae)was the most common cause of pyogenic hepatic abscess at ourinstitution over the last5-yr period.When comparing Klebsiella versus other causes of pyogenicliver abscess,there were no significant differences in demographics or laboratoryfindings;however,most of our Klebsiella cases occurred among Filipinos.Review of the18cases of K.pneumoniaeliver abscess in the United States showed that Klebsiella cases occurred predominantly amongmiddle-aged men;83%had concurrent bacteremia and28%had metastatic complications.Anincreasing number of cases were reported from the United States since the mid-1990s.CONCLUSIONS:These data suggest that KLA may represent an emerging disease in Western countries,such as the United States.The diagnosis of K.pneumoniae should be considered in all cases of liver abscess,and appropriate antibiotic therapy and a diagnostic work-up for metastatic complications should beemployed.(Am J Gastroenterol2005;100:322–331)INTRODUCTIONLiver abscess is a common intraabdominal infection that may be caused by bacterial,fungal,or parasitic organisms. Until the end of the last century,Escherichia coli(E.coli) was the predominant bacterial cause of pyogenic(bacterial or fungal)liver abscesses.In the1990s Klebsiella pneumo-niae liver abscess(KLA)wasfirst described as an emerg-ing disease in Taiwan,which affected diabetic,middle-aged men and led to metastatic complications,most notably en-dophthalmitis,in a large percentage of cases.Reports of KLA have been accumulating from Asian and Western coun-tries alike.In order to investigate this trend further,we examined the microbiologic causes of pyogenic liver ab-scess at our institution for the past5yr and reviewed all case reports of KLA in the United States through the year 2003.METHODSWe queried the inpatient records at the Naval Medical Cen-ter San Diego,San Diego,CA(a500-bed teaching insti-tution servicing active duty military members,their depen-dents,and retirees in the Southern California area)for all cases of liver abscess(discharge diagnosis of“liver abscess”and with corresponding radiographicfindings)between1999 and2003and compiled demographic and clinical informa-tion for these cases.In addition,a MEDLINE search was performed from1966to2003using key words Klebsiella and liver abscess(limited to English language)to identify all KLA reported in the United States.Descriptive statis-tics were performed as well as univariate analyses utiliz-ing Fisher’s exact tests for dichotomous variables and t-tests for continuous variables(Epi Info TM version3.2.2,Atlanta, GA).322Klebsiella Liver Abscess 323RESULTSCase 1A 50-yr-old Filipino male presented with a 5-day history of fevers,rigors,nausea,and myalgias.He was previously in good health except for noninsulin-dependent diabetes melli-tus and essential thrombocytosis,treated with glyburide and hydroxyurea,respectively.He denied abdominal pain,diar-rhea,or visual changes.On examination,his temperature was 101.1o F .He was in mild distress,but had a normal examina-tion except for scleral icterus and mild abdominal distension without tenderness or organomegaly.Laboratory values were remarkable for a leukocytosis of 23,100cells/mm 3,total bilirubin 3.7mg/dl,albumin 2.7g/dl,alkaline phosphatase 274IU/L,alanine transferase 589IU/L,and aspartate transferase 357IU/L.Glycosylated hemoglobin was 12.3%.A right upper quadrant ultrasound revealed mul-tiple foci of decreased echogenicity throughout the liver with-out gallbladder pathology.A CT scan showed too numerous to count,0.5–1.5-cm attenuations in the liver,especially in the right lobe consistent with multiple abscesses (Fig.1);other abdominal structures appeared normal.A biliary scan and MRI showed a nonobstructive biliary system.An upper and lower endoscopy were unrevealing.The patient was empirically treated with intravenous piperacillin-tazobactam (3.375g)every 6h and gentamicin (400mg)daily.Two of six blood cultures grew Klebsiella pneumoniae (K.pnemoniae )sensitive to all antibiotics ex-cept ampicillin.Entamoeba histolytica (E.histolytica )serol-ogy was negative.Antibiotics were switched to ceftriaxone (2g)daily and oral metronidazole (500mg)four timesdailyFigure 1.CT scan demonstrating numerous small hepatic abscesses due to K.pneumoniae .during his inpatient stay;he was treated as an outpatient with levofloxacin and metronidazole for 4wk.A repeat CT scan showed complete resolution of all liver abscesses,and he has remained healthy over an 18-month period.Case 2A 71-yr-old Caucasian male with a past medical history only significant for coronary artery disease acutely developed fevers of 102o F and abdominal pain followed by hypotension.The patient did not report any changes in vision.He denied any significant travel history.After stabilization in the inten-sive care unit with fluids and vasopressors,the patient was found to have positive blood cultures for K.pneumoniae ,and an abdominal CT scan revealed a 7-cm hepatic abscess in the left lobe.CT -guided percutaneous drainage revealed K.pneu-moniae sensitive to all tested antibiotics except ampicillin.E.histolytica serology was negative.Two days after discharge,the patient noted low-grade fevers up to 100.2o F ,chills,and recurrent abdominal boratory values were normal except for an albumin of 2.5g/dl,alkaline phosphatase of 469IU/L,alanine transferase 98IU/L,and aspartate transferase 170IU/L.Repeat blood cultures and a chest radiograph were unremarkable.A CT scan showed a 10×6×6.5cm multiloculated abscess in the left hepatic lobe.The patient was treated with intravenous ce-fotetan (2g)twice daily and oral levofloxacin (500mg)daily for 8wk.Right upper quadrant ultrasound showed no biliary pathology,and colonoscopy was normal.Imaging 6months later showed no abnormalities,and the patient has remained well except for recurrent angina over the past 4yr.Case 3A 53-yr-old Caucasian male with a history of mitral valve prolapse and hypercholesterolemia reported a 3-wk history of fatigue and malaise,as well as 1wk of fevers,rigors,night sweats,and tooth pain.His examination was remark-able for a temperature of 100.6o F ,a mid systolic click,and a normal S1and S2.There were no petechiae,Osler’s nodes,Janeway lesions,or Roth spots,and the remainder of his ex-amination was boratory values revealed a white blood count of 11,300cells/ml,total bilirubin of 1.2mg/dl,alkaline phosphatase of 137IU/L,alanine transferase of 68IU/L,aspartate transferase of 67IU/L,and albumin of 3.5g/dl.On day 1of hospitalization,one of eight blood cultures from admission grew gram-negative rods,later identified as K.pneumoniae .A follow-up transesophageal echocardio-gram was negative.A CT scan of the abdomen was performed to determine the source of the Klebsiella ;it revealed a 7×6cm abscess in the left lobe of the liver (Fig.2).A right upper quadrant ultrasound and biliary scan were normal.CT -guided drainage of the abscess yielded purulent material that grew K.pneumoniae .The patient received 4wk of ceftriaxone and metronidazole along with 2wk of gentamicin;he was then transitioned to oral ciprofloxacin for 1month.A follow-up324Lederman andCrumFigure 2.CT scan demonstrating a single large K.pneumoniae liver abscess.CT showed complete resolution of the abscess,and he has remained well over the past 3yr.Case 4A 64-yr-old Filipino female presented with a 2-day history of right upper quadrant abdominal pain,anorexia,and fever.Her past medical history was significant for peptic ulcer disease,coronary artery disease,and hypertension.She de-nied visual changes.Examination revealed a temperature of 101.1o F ,mild tenderness in the right upper quadrant and epi-gastrum without rebound tenderness,guarding,mass,or hep-atomegaly.Laboratory values were remarkable for a white blood count of 19,900cells/mm 3.Total bilirubin was 1.2mg/dl,albu-min 3.7g/dl,alkaline phosphatase 80IU/L,alanine trans-ferase 41IU/L,and aspartate transferase 30IU/L;all other chemistries were normal with a glucose of 120mg/dl.A right upper quadrant ultrasound revealed a 4.0cm ×2.4cm ×3.4cm lesion with multiple thick internal septations and a 1.0cm ×1.3cm ×1.4cm lesion both in the left lobe of the liver.A CT scan showed several lesions in the left lobe of the liver consistent with multiple abscesses;other abdomi-nal structures appeared normal.An upper endoscopy showed diffuse antral and duodenal erosions;colonoscopy was normal.The patient was empirically treated with intravenous ciprofloxacin (400mg)twice daily and metronidazole (500mg)three times daily.Eight blood cultures and E.histolytica serology were negative.Percutaneous drainage of a liver le-sion grew K.pneumoniae sensitive to all antibiotics except ampicillin.The patient clinically improved and was given a 6-wk course of oral ciprofloxacin and metronidazole.She re-turned to her usual state of health and was subsequently lost to follow-up.Case 5A 56-yr-old Filipino male presented with a 5-day history of fevers,chills,and night sweats,as well as 3days of epigastric pain and nausea.He denied recent travel or vi-sual changes.Examination revealed an initial temperature of 99.5o F and mild tenderness in the right upper quadrant and epigastrum without rebound or guarding;the remainder of the examination was unremarkable.During the first 6h,the patient became markedly hypotensive but responded to fluid boluses.Laboratory values were remarkable for a white blood count of 17,800cells/ml,total bilirubin 3.8mg/dl,direct bilirubin 2.4mg/dl,albumin 2.8g/dl,alkaline phosphatase 200IU/L,alanine transferase 156IU/L,aspartate transferase 116IU/L,and glucose 149mg/dl.Creatinine was elevated at 1.7mg/dl,and urine electrolyte studies were consistent with prerenal azotemia.A right upper quadrant ultrasound revealed a 5-cm lesion in the right lobe of the liver.A CT scan showed a 7.6×6.5×7.5cm low-attenuation mass in the right lobe consistent with an abscess;other abdominal structures were unremarkable.The patient was empirically treated with intravenous piperacillin/tazobactam every 6h,metronidazole (500mg)every 8h,and gentamicin (180mg)every 18h.T wo of four blood cultures grew K.pneumoniae sensitive to all antibiotics except ampicillin.A pigtail drain was placed into the liver ab-scess yielding 50cc of pus that also grew K.pneumoniae.E.histolytica serology was negative.A dilated fundoscopic ex-amination was unremarkable.The patient clinically improved and antibiotics were switched to oral levofloxacin (500mg)daily and metronidazole (500mg)three times daily for a 6-wk course.A follow-up CT scan after antibiotic therapy showed abscess boratories returned to baseline includ-ing the creatinine (1.0mg/dl).The patient has remained well over the past 30months.Case 6A 59-yr-old Filipino female presented with a 3-day history of fevers of 103◦F ,chills,anorexia,and fatigue.She noted no visual complaints.She had a history of noninsulin-dependent diabetes mellitus.She emigrated in 1967to the United States from Luzon,Philippines.Examination was remarkable for a temperature of 102.2◦F boratory findings included a white blood count of 19,800mm 3,creatinine 3.3mg/dl,glucose 120mg/dl,total bilirubin 1.8mg/dl,alanine trans-ferase 133IU/L,asparate transferase 156IU/L,alkaline phos-phatase 101U/L,and albumin 2.1g/dl.A CT scan of the abdomen showed an 8cm ×8cm ×4.4cm lesion,with internal higher attenuated septa/regions,in the anterior as-pect of the left lobe of the liver.The patient was empirically treated with piperacillin-tazobactam (3.375g)every 6h and metronidazole (500mg)every 8h.Klebsiella Liver Abscess325Table1.Demographics and Laboratory Values of Liver Abscess CasesAspartate Alanine Total Alkaline Age Causative Leukocytes Aminotransferase Aminotransferase Bilirubin Albumin Phosphatase No.(yr)Gender Race Organism(s)(mm3)(IU/L)(IU/L)(mg/dl)(g/dl)(IU/L) 150Male Filipino K.pneumoniae23.1357589 3.7 2.7274 271Male Caucasian K.pneumoniae9.6170980.9 2.5469 353Male Caucasian K.pneumoniae11.36768 1.2 3.5137 464Female Filipino K.pneumoniae19.93041 1.2 3.780 556Male Filipino K.pneumoniae17.8156116 3.8 2.8200 659Female Filipino K.pneumoniae19.8133156 1.8 2.1101 762Male Caucasian E.histolytica19.7107148 1.1 2.8278 829Female Caucasian E.histolytica12.425350.9 3.0196 971Male Caucasian E.coli K.oxytoca 4.530300.5 2.2119 1025Male Caucasian Fusobacterium10.83830 1.0 2.6309necrophorum1147Male Filipinoα-streptococcus,28.724571246 1.5 2.974E.coli1237Female Filipino E.coli7.824240.8 3.3124 1371Female Caucasian P.aeruginosa28.3808522.3 1.3228Enterococcus sp.1487Male Caucasian Enterococcus sp.44.22416 3.6 2.295 1544Male Africanα-streptococcus16.279139 1.3 3.0109 American1663Male Caucasian Unknown20.234480.6 2.595 1731Male Filipino Unknown10.64581 1.4 2.9350 1837Male African Unknown18.73048 1.0 2.2105 American1957Male Hispanic Unknown9.04176 1.0 2.776 2012Male Caucasian Unknown14.532450.5 2.8233One of four blood cultures grew K.pneumoniae,resis-tant to only ampicillin.CT-guided drainage of the abscess yielded purulentfluid,which grew K.pneumoniae.Urine cul-ture was negative.Antibiotics were switched to ceftriaxone (2g)daily and metronidazole(500mg)every8h for4wk, followed by oral levofloxacin(500mg)daily for3months. Follow-up imaging showed complete resolution of the liver abscess.We identified20cases of liver abscesses from our inpa-tient and outpatient hospital records between1999and2003. We identifiedfive other cases under this discharge diagno-sis,which we excluded based on patient record and radio-graphicfindings(two with hepatic candidiasis,one with an infected hepatic cyst,one with necrotic lesion after cryoab-lation,one with an infected biloma).The etiology,laborato-ries,and demographics of the20cases are summarized in Table1.KLA accounts for30%of liver abscesses for the past5yr at our institution,surpassing the incidence of E. coli as a liver abscess pathogen.Patients at our institution with KLA were predominantly male(2:1)and had an aver-age age of58.8yr(range50–71yr).Patients with pyogenic abscess due to other bacterial etiology were also predomi-nantly male(2:1)and had the same approximate age(mean age54.6yr with a range of25–87yr).Sixty-seven percent of KLA were Filipinos compared to29%of those with other types of bacterial liver abscesses,but this was not significantly different(p-value0.17).We compared the laboratory values between these groups and found no statistically significant differences.From our MEDLINE search,12cases of K.pneumo-niae case reports were identified(1–12).Demographics and clinical characteristics including our six cases are shown in Table2.In summary,the mean age of patients(excluding the newborn)was46yr;they were predominantly male(2:1),and one-third were diabetic.Sixty-seven percent of patients had a single abscess,83.3%had positive blood cultures,27.8% suffered metastatic complications,and the overall mortality rate was5.6%.Interestingly,more than75%of cases were reported since the mid-1990s.DISCUSSIONOne out of every4,500–7,000hospital admissions is due to a liver abscess(13,14).Liver abscesses may be separated into two major categories:pyogenic(bacterial and fungal)and amoebic;up to2.5%of amoebic liver abscesses may contain bacterial pathogens as well(15).Pyogenic abscesses account for three-quarters of liver abscesses in industrialized coun-tries(16).A bacterial pathogen may be identified in two-thirds of cases of liver abscesses(17).The most common bacteria isolated from liver abscess patients are gram-negative rods. Prior to the1980s,E.coli was the most commonly isolated organism from liver abscess patients,but more recently,K. pneumoniae has been found to be the number one pathogen in Taiwan(18).The average age of patients with KLA is55–60 yr(18,19)and KLAs are twice as likely to be diagnosed in men than women(19,20).Reports of KLA in children are rare(1).326Lederman and CrumT a b l e 2.K l e b s i e l l a L i v e r A b s c e s s C a s e s i n t h e U n i t e d S t a t e s ,1966–2003U n d e r l y i n g P o s i t i v e C a s e A g e M e d i c a l C u l t u r e (s )f o r H e p a t i c M e d i c a l P r o c e d u r e E x t r a h e p a t i c N o .R e f e r e n c e Y r(y r )S e x R a c eC o n d i t i o n (s )K l e b s i e l l aL e s i o n (s )T h e r a p y (s )C o m p l i c a t i o n s O u t c o m e1(1)1974N e w b o r n FA f r i c a n A m e r i c a n H y p o c a l c e m i a ,S G A ,u m b i l i c a l v e i n c a t h e t e r i n d u c e d p y l e p h l e b i t i sB l o o d a n d s p i n a l flu i d 3.5-c m s i n g l e a b s c e s s ,r i g h t l o b eP e n i c i l l i n a n d k a n a m y c i n N o n e M e n i n g i t i s ,u m b i l i c a l v e i n p y l e -p h l e b i t i s ,p n e u m o n i a .D i e d2(2)197848M A f r i c a n A m e r i c a n N o n e L i v e r a s p i r a t e a n d u r i n e9-c m s i n g l e a b s c e s s ,r i g h t l o b e N RL a p a r o t o m y w i t h d r a i n a g eB i l a t e r a l t i b i a l o s t e o m y e l i -t i s S u r v i v e d3(3)198070F N RP a n c r e a t i c c a n c e r s /p W h i p p l e p r o c e d u r e 10y r p r i o r B l o o d a n d l i v e r a s p i r a t eD i f f u s e h e p a t i t i s w i t h o u t d i s t i n c t a b s c e s s P e n i c i l l i n a n d g e n t a m i c i n S u r g i c a l e x p l o r a t i o n w i t h b i o p s i e sN o n eS u r v i v e d4(4)199437M N RH e m o r r h o i d e c t o m yB l o o d a n d l i v e r a s p i r a t e7-c m s i n g l e a b s c e s s ,l e f t l o b e P e n i c i l l i n ,g e n t a m i c i n ,m e t r o n i d a z o l e ×6w k P e r c u t a n e o u s c a t h e t e r d r a i n a g e N o n eS u r v i v e d5(5)199450F N RC h o l e d o c h o l i t h i a s i sB l o o dM u l t i p l e l e s i o n s ,b o t h l o b e sC e f o t a x i m e a n d m e t r o n i d a z o l e ,f o l l o w e d b y c e f a z o l i n d u r a t i o n N R C o m m o n b i l e d u c t s t e n t N o n eS u r v i v e d6(6)199961M N R N o n eB l o o d a n d l i v e r a s p i r a t e 5-c m a b s c e s s ,r i g h t l o b eC e f t i z o x i m e a n d m e t r o n i d a z o l e P e r c u t a n e o u s c a t h e t e r d r a i n a g eE n d o p h t h a l m i t i s ,b i l a t e r a l p n e u m o n i a S u r v i v e d ,r e q u i r e d e y e p r o s t h e s i s 7(7)199938MA f r i c a n A m e r i c a n D i a b e t e s (n e w l yd i a g n o se d )L i v e r a s p i r a t e ,C S F S i n g l e l e s i o n ,r i g h t l o b eC e f t r i a x o n e f o r 21d a y s a n d m e t r o n i d a z o l e f o r 17d a y s ,f o l l o w e d b y o r a l l e v o flo x a c i n a n d m e t r o n i d a z o l e f o r 30d a y s ;p e r c u t a n e o u s d r a i n a g e P e r c u t a n e o u s d r a i n a g e M e n i n g i t i s ,u n i l a t e r a l e n d o p h -t h a l m i t i sS u r v i v e d 8(8)200032M N /AB e t a -t h a l a s s e m i a ,s p l e n e c t o m yB l o o d a n d v i t r e o u s a s p i r a t eT w o l e s i o n s ,l o c a t i o n N RP i p e r a c i l l i n /t a z o b a c t a m a n d g e n t a m i c i n f o r 3d a y s ,c e f t r i a x o n e ,g e n t a m i c i n ,m e t r o n i d a z o l e +i n t r a v i t r e a l a m i k a c i n a n d v a n c o m y c i n l e n g t h N R ,c i p r o flo x a c i n l e n g t h N RP e r c u t a n e o u s d r a i n a g e ;v i t r e c t o m y a n d r e t i n e c t o m y R e n a l a b s c e s s ,u n i l a t e r a l e n d o p h -t h a l m i t i sS u r v i v e d ,v i s i o n 20/30c o r r e c t a b l ec o n t i n u e dKlebsiella Liver Abscess327T a b l e 2.C o n t i n u e dU n d e r l y i n g P o s i t i v e C a s e A g e M e d i c a l C u l t u r e (s )f o r H e p a t i c M e d i c a l P r o c e d u r e E x t r a h e p a t i c N o .R e f e r e n c eY r(y r )S e x R a c eC o n d i t i o n (s )K l e b s i e l l aL e s i o n (s )T h e r a p y (s )C o m p l i c a t i o n s O u t c o m e9(9)200068MW e s t I n d i a n o r i g i n N o n i n s u l i n d e p e n d e n t d i a b e t e s m e l l i t u s B l o o d a n d l i v e r a s p i r a t e5-c m l i v e r a b s c e s s ,l e f t l o b e N R P e r c u t a n e o u s c a t h e t e r d r a i n a g e N o n eS u r v i v e d10(10)200157FA f r i c a n A m e r i c a n N o n i n s u l i n d e p e n d e n t d i a b e t e s m e l l i t u s ;c y s t i c d u c t o b s t r u c t i o nB l o o d a n d l i v e r a s p i r a t eM u l t i p l e l e s i o n s ,b o t h l o b e sC i p r o flo x a c i n a n d c l i n d a m y c i n ×26d a y s ,t h e n p i p e r -c i l l i n /t a z o b a c t a m a n d g e n t a m i c i n d u r a t i o n N RC h o l e c y s t e c t o m y a n d o p e n d r a i n a g e o f l a r g e l i v e r a b s c e s s f o l l o w e d b y p e r c u t a n e o u s d r a i n a g e o f s m a l l e r l i v e r l e s i o n s N o n e ∗S u r v i v e d11(11)200129M N R N o n eB l o o d a n d l i v e r a s p i r a t e7-c m s i n g l e a b s c e s s ,r i g h t l o b e P i p e r a c i l l i n /t a z o b a -c t a m a n d m e t r o -n i d a z o l e ×6w k P e r c u t a n e o u s d r a i n a g eN o n e ∗∗S u r v i v e d12(12)200362M C a u c a s i a nD i a b e t e s m e l l i t u sB l o o d a n d l i v e r a s p i r a t e S i n g l e l e s i o n ,r i g h t l o b eC i p r o flo x a c i n a n d I m i p e n e m P e r c u t a n e o u s c a t h e t e r d r a i n a g e N o n eS u r v i v e d13C u r r e n t C a s e 200350M F i l i p i n oN o n i n s u l i n d e p e n d e n t d i a b e t e s m e l l i t u sB l o o d a n d l i v e r a s p i r a t eM u l t i p l e l e s i o n s ,b o t h l o b e sP i p e r a c i l l i n /t a z o -b a c t a m a n d g e n t a m i c i n ,f o l l o w e d b y c e f t r i a x o n e a n d m e t r o n i d a z o l e ×4w k ,t h e n l e v o flo x a c i n a n d m e t r o n i d a z o l e ×4w k P e r c u t a n e o u s d r a i n a g eN o n eS u r v i v e d14C u r r e n t C a s e 200371M C a u c a s i a nC o r o n a r y a r t e r y d i s e a s e B l o o d a n d l i v e r a s p i r a t e 10-c m l i v e r a b s c e s s ,l e f t l o b e C e f o t e t a n a n d l e v o flo x a c i n ×8w k P e r c u t a n e o u s d r a i n a g eN o n eS u r v i v e d15C u r r e n t C a s e 200353M C a u c a s i a nN o n e B l o o d a n d l i v e r a s p i r a t e7-c m l i v e r a b s c e s s ,l e f t l o b e C e f t r i a x o n e a n d m e t r o n i d a z o l e ×4w k (g e n t a m i c i n g i v e n f o r 2w k ),t h e n c i p r o flo x a c i n ×4w k P e r c u t a n e o u s d r a i n a g eN o n eS u r v i v e d16C u r r e n t C a s e 200364F F i l i p i n oP e p t i c u l c e r d i s e a s e ,c o r o n a r y a r t e r y d i s e a s e ,h y p e r t e n s i o nL i v e r a s p i r a t e4-c m -a n d 1.5-c m l e s i o n s ,l e f t l o b e C i p r o flo x a c i n a n d m e t r o n i d a z o l e ×6w kP e r c u t a n e o u s d r a i n a g eN o n e S u r v i v e d328Lederman and CrumT a b l e 2.C o n t i n u e dU n d e r l y i n g P o s i t i v e C a s e A g e M e d i c a l C u l t u r e (s )f o r H e p a t i c M e d i c a l P r o c e d u r e E x t r a h e p a t i c N o .R e f e r e n c eY r(y r )S e x R a c eC o n d i t i o n (s )K l e b s i e l l aL e s i o n (s )T h e r a p y(s )C o m p l i c a t i o n s O u t c o m e17C u r r e n t C a s e 200356M F i l i p i n o H y p e r t e n s i o nB l o o d a n d l i v e r a s p i r a t e8-c m l e s i o n ,r i g h t l o b eP i p e r a c i l l i n /t a z o b a -c t a m ,g e n t a m i c i n a n d m e t r o n i d a z o -l e ×9d a y s ,t h e n l e v o flo x a c i n a n d m e t r o n i d a z o l e f o r 6w k P e r c u t a n e o u s d r a i n a g eN o n e †S u r v i v e d18C u r r e n t C a s e 200359FF i l i p i n o D i a b e t e s m e l l i t u s ,c o r o n a r y a r t e r y d i s e a s eB l o o d a n d l i v e r a s p i r a t e8-c m l e s i o n ,l e f t l o b eP i p e r a c i l l i n /t a z o b -a c t a m a n d m e t r o -n i d a z o l e ,t h e n c e f t r i a x o n e a n d m e t r o n i d a z o l eP e r c u t a n e o u s d r a i n a g eH y p o t e n s i o n (flu i d r e -s p o n s i v e )S u r v i v e d∗P a t i e n t i n i t i a l l y r e f u s e d s u r g i c a l d r a i n a g e r e s u l t i n g i n p e r s i s t e n t f e v e r s a n d a b s c e s s ;a f t e r s e c o n d a d m i s s i o n a s u r g i c a l p r o c e d u r e w a s p e r f o r m e d a n d t h e i n f e c t i o n c l e a r e d .∗∗F a i l e d p e r c u t a n e o u s d r a i n a g e o f m u l t i l o c u l a t e d a b s c e s s r e s u l t e d i n o p e n d e b r i d e m e n t a n d p a r t i a l l o b e c t o m y .†S e p s i s ,a c u t e r e n a l f a i l u r e ,a n d D I C w i t h f u l l r e c o v e r y .N R =n o t r e p o r t e d ;SG A =s m a l l f o r g e s t a t i o n a l a g e .Gram-positive organisms such as S.aureus and leri are reported less frequently (18,14)and are likely to be found in the setting of secondary hepatic lesions (i.e.,the primary source is from outside the abdomen).Recovery of anaerobic organisms is challenging,and therefore may not be identified in true mixed infections (17);in series where careful attention is paid to anaerobic organism recovery,they may be detected in 10–17%of cases,most often B.fragilis (18,20).Anaerobes were recovered from 20%of our non-KLA bacterial liver abscess patients.Recovery of organisms,particularly those that are anaerobic,is more likely from abscess aspiration than from blood cultures (14,18,21).All anaerobes from our series were recovered from abscess aspiration with the exception of the one case of Fusobacterium necrophorum .Mixed infections may be found in 14–55%of cases of routine pyogenic liver abscesses (18,20,22),but KLA cases are almost uniformly monobacterial.Prior to the era of rapid patient assessment and expeditious surgery,appendiceal pathology was the most common source of liver abscesses (23).In the modern era,biliary disease is the most common etiology (17,20).Other potential sources include penetrating trauma,distant sources (i.e.,outside the abdomen),and contiguous spread from lung,kidney,colon,or stomach.Still,many are deemed cryptogenic (14,17,19,20)(40–99%);abscesses containing only K.pneumoniae are much more likely to be cryptogenic (64%)(24).The first purported case of KLA with metastatic complica-tions reported in the United States was in an African Ameri-can diabetic man in 1999(7).However,Seeto et al.reported pure cultures of K.pneumoniae in 13of 140pyogenic liver abscess cases during the period 1979–1994;hence,a shift from E.coli to K.pneumoniae may have been present for over a decade in the United States but was unrecognized (14).In a case series by Hansen and Vargish,Klebsiella spp.was the most common bacterium isolated from liver abscesses,but it is unclear if these cases were polymicrobial (25)and thus would not be representative of KLA strictu sensu .In the past 5yr,we have observed six cases at our institution alone,four of which involved nondiabetic patients.This is an interesting institutional trend and may herald the beginnings of a shift in microbiologic etiology of liver abscess in the United States not unlike that seen in Taiwan over a decade ago.The first reports of a significant rise in incidence of KLA originated from Taiwan;however,other Asian (Japan (17,26,27),Singapore (28,29),Korea (30),India (31),Hong Kong (32)),and non-Asian (Spain (33),United States (7,10,12,58),England (34),Trinidad (35),Australia (36))coun-tries have followed suit.Many of the reports from non-Asian countries may involve patients of Asian descent but whether the patients are Asian or not,they nearly always have poorly controlled diabetes (19,24,26,34).Diabetes is a known risk factor for developing KLA,and it appears to be a signifi-cant risk factor for embolic complications (37),especially endophthalmitis (38).The diagnosis of diabetes may come to light because of the discovery of the KLA (7).In addition。
因肺炎克雷伯的原发性肝脓肿
1434Primary Liver Abscess Due to Klebsiella pneumoniae in TaiwanJen-Hsien Wang,Yung-Ching Liu,Susan Shin-Jung Lee,From the Section of Infectious Diseases,Department of InternalMedicine,Veterans General Hospital-Kaohsiung,Kaohsiung,Taiwan, Muh-Yong Yen,Yao-Shen Chen,Jao-Hsien Wang,Republic of China Shue-Ren Wann,and Hsi-Hsun LinPyogenic liver abscess is an uncommon complication of intra-abdominal or biliary tract infectionand is usually a polymicrobial infection associated with high mortality and high rates of relapse.However,over the past15years,we have observed a new clinical syndrome in Taiwan:liver abscessescaused by a single microorganism,Klebsiella pneumoniae.We reviewed182cases of pyogenic liverabscess during the period September1990to June1996;160of these cases were caused byK.pneumoniae alone,and22were polymicrobial.When patients with K.pneumoniae liver abscesswere compared with those who had polymicrobial liver abscess,we found higher incidences ofdiabetes or glucose intolerance(75%vs.4.5%)and metastatic infections(11.9%vs.0)and lowerrates of intra-abdominal abnormalities(0.6%vs.95.5%),mortality(11.3%vs.41%),and relapse(4.4%vs.41%)in the former group.Liver abscess caused by K.pneumoniae is a new clinicalsyndrome that has emerged as an important infectious complication in diabetic patients in Taiwan.Pyogenic liver abscess is an uncommon complication of is also obtained.Pigtail catheter drainage is the major treatmentstrategy unless multiple microabscesses are present,in which intra-abdominal or biliary tract infection,despite the high inci-dence of cholecystitis,appendicitis,diverticulitis,and peritoni-case,fine-needle aspiration is satisfactory for both diagnosisand treatment.Patients’clinical courses are usually uneventful tis worldwide[1–3].The infection may be due to direct exten-sion from contiguous structures or to hematogenous spread if successful pigtail catheter drainage is combined with a3-week course of parenteral antimicrobial treatment.Pigtail from a remote infectious focus such as appendicitis or divertic-ulitis[3].Pyogenic liver abscess is usually polymicrobial be-catheter drainage is usually continued for1–2weeks,and thedrain is removed when the following criteria are met:cultures cause of the ascending route of infection from the gastrointesti-nal tract[1,4–6].Over the past15years in Taiwan,we have of the liver abscess become sterile,the daily drainage outputisõ5mL for several days,and defervescence occurs even seen many cases of pyogenic liver abscess that have beencontrary to the rule.In Taiwan,liver abscesses caused by a after the drainage tube is clamped.We usually maintain oralantimicrobial treatment for1–2months after discharge from single pathogen,Klebsiella pneumoniae,occur in diabetic pa-tients without intra-abdominal or biliary tract infection.the hospital to consolidate the effect of treatment.We reviewed182cases of pyogenic liver abscesses treated K.pneumoniae liver abscess is a well-known disease inTaiwan that presents as an infectious complication in diabetic at the Veterans General Hospital-Kaohsiung(Taiwan)fromSeptember1990to June1996and compared the epidemiologi-patients[7].It has been an endemic disease for at least15years.Infectious diseases specialists in Taiwan have reached cal features,clinical presentations,treatment strategies,andoutcomes of K.pneumoniae liver abscess with those of polymi-a consensus on the diagnosis and management of K.pneumo-niae liver abscess;this consensus has also been applied to poly-crobial liver abscess.microbial liver abscess.Diagnostic examinations include threesets of blood cultures and CT-or ultrasonographically-guidedMaterials and Methodsaspiration of the abscess,with or without pigtail catheter drain-age,to obtain a specimen for gram staining and aerobic/anaero-Veterans General Hospital-Kaohsiung,a1,000-bed facility, bic cultures.is one of the11medical centers in Taiwan and has been a Routine tests performed on admission in our hospital include reference center for four southern counties and one metropoli-CT scanning of the whole abdomen to rule out the possibility tan area since September1990.In our hospital the diagnostic of a tumor or biliary tract stones,HIV serology,and blood and therapeutic strategies for pyogenic liver abscess are based chemistry and fasting blood sugar determinations;a hemogram on the aforementioned consensus.We retrospectively reviewedthe medical and microbiological records at Veterans GeneralHospital-Kaohsiung to identify patients with the diagnosis ofK.pneumoniae abscess and polymicrobial liver abscess during Received16October1997;revised12February1998.the period September1990to June1996.Reprints or correspondence:Dr.Jen-Hsien Wang,Section of Infectious Dis-eases,Department of Internal Medicine,Veterans General Hospital-Kaohsiung,Cases were considered to be K.pneumoniae liver abscess if 386Ta-Chung1st Road,Kaohsiung,Taiwan813,Republic of China.a bacterial culture of blood or of pus from a CT-confirmed Clinical Infectious Diseases1998;26:1434–8liver abscess was positive for K.pneumoniae and a gram stain ᭧1998by the Infectious Diseases Society of America.All rights reserved.1058–4838/98/2606–0033$03.00of the pus showed only gram-negative bacilli.Cases were con- at Wenzhou Medical College on December 3, 2012 / Downloaded from1435 CID1998;26(June)K.pneumoniae Liver Abscess in TaiwanTable1.Clinical characteristics of Klebsiella pneumoniae liver ab-sidered to be polymicrobial liver abscess if a gram stain of thescess and polymicrobial liver abscess in patients at Veterans General pus obtained from a CT-confirmed liver abscess showed mixedHospital-Kaohsiung,Taiwan,September1990to June1996. bacterialflora.After the cases were morphologically and micro-biologically confirmed as K.pneumoniae abscess or polymi-K.pneumoniae Polymicrobialcrobial liver abscess,demographic data,clinical presentations,liver abscess liver abscessVariable(nÅ160)(nÅ22)P value* risk factors,and treatment outcomes were gathered from themedical records and reviewed.Ratio of males to females 2.40(113:47) 2.67(16:6).418 After consensus as to the diagnosis was reached,CT of theMean age(y)58.062.6... whole abdomen was routinely performed on admission for any Fever(oral temperature,suspected cases to confirm the morphological diagnosis andú38ЊC)148(92.5)18(81.8).104RUQ tenderness to percussion114(71.2)15(68.2).386 to rule out the possibility of intrahepatic and intra-abdominalNausea,vomiting,diarrhea,orabnormalities.All patients with morphologically proven liverabdominal pain61(38.1)7(31.8).277 abscess underwent immediate pigtail catheter drainage orfine-Cough or dyspnea18(11.3)1(4.5).094 needle aspiration of the abscess for etiologic diagnosis and Leukocytosis(ú10,000cells/treatment.Every patient with a microbiologically proven case mm3)112(70)16(72.7).394Aspartate aminotransferasereceived parenteral antimicrobial treatment according to sus-level,ú45U/L108(67.5)15(68.2).474 ceptibility test results for at least3weeks.Alanine aminotransferaseIn studying the risk factors for K.pneumoniae and polymi-level,ú40U/L95(59.4)10(45.5).109 crobial liver abscesses,we analyzed HIV serostatus;history of Alkaline phosphatase level,steroid use;and the presence of intrahepatic abnormalities,ú95U/L125(78.1)22(100)õ.001Total bilirubin,ú1.6mg/dL41(25.6)12(54.5)õ.001 malignancies,or diabetes mellitus.We defined diabetes melli-Metastatic infections19(11.9)0õ.001 tus as a random plasma glucose level ofú200mg/dL,a fastingDeath18(11.3)9(41)õ.001 plasma glucose level ofú140mg/dL or a fasting venous wholeRelapse7(4.4)9(41)õ.001 blood glucose level ofú120mg/dL on more than one occasion,NOTE.Data are number of patients(%)unless otherwise indicated.RUQ or abnormal results of an oral glucose tolerance test performedÅright upper quadrant.under standardized conditions,with the glucose levels at2*P values were estimated by using the binomial test for two independenthours and in at least one other sample exceeding200mg/dL.samples.The term impaired glucose tolerance was reserved for patientswith glucose tolerance results that fell between normal andfrank diabetes.Glucose tolerance tests were performed for all(81.8%),was the most common presenting symptom for bothtypes of liver abscesses.Tenderness to percussion over the right patients with pyogenic liver abscess who did not have frankdiabetes mellitus during the convalescent stage.upper quadrant of the abdomen was also common,occurring in71.2%and68.2%of patients with K.pneumoniae liver ab-All statistical analyses were performed with the binomialtest for two independent samples,and P values were calculated scesses and polymicrobial liver abscesses,respectively.Otherabdominal complaints such as nausea,vomiting,diarrhea,and to express the difference between two groups.abdominal pain were less common,occurring in only38.1%and31.8%cases of K.pneumoniae liver abscess and polymi-Resultscrobial liver abscess,respectively.Chest complaints were rareand were found in only11.3%of cases of K.pneumoniae One hundred eighty-two patients with K.pneumoniae andpolymicrobial liver abscesses were enrolled in this study,which liver abscess and4.5%of cases of polymicrobial liver abscess.Clinically,there were no significant differences between these was conducted from September1990to June1996.Of thesepatients,160(87.9%)had liver abscesses caused by a single two types of liver abscesses.Laboratoryfindings for patients with K.pneumoniae and microorganism,K.pneumoniae,and22(12.1%)had liver ab-scesses caused by mixedflora.The male-to-female ratio was polymicrobial liver abscess are shown in table1.Leukocytosis(70%of patients with K.pneumoniae abscess vs.72.7%of 2.40(113:47)in the group with abscesses due to K.pneumoniaeand2.67(16:6)in the group with polymicrobial abscesses.The patients with polymicrobial liver abscess),elevated aspartateaminotransferase levels(67.5%vs.68.2%),and elevated ala-mean age was58.0years in the former group and62.6yearsin the latter group(table1).There was no specific geographic nine aminotransferase levels(59.4%vs.45.5%)were seen inboth groups;the difference was not significant.Higher inci-distribution for either group in the referral area covered byVeterans General Hospital-Kaohsiung.dences of elevated total bilirubin levels and alkaline phospha-tase levels were observed for patients with polymicrobial liver Clinical presentations of K.pneumoniae and polymicrobialliver abscesses are summarized in table1.Fever(oral tempera-abscesses(54.5%vs.25.6%and100%vs.78.1%,respectively).Metastatic infection was a characteristic feature of K.pneu-ture,ú38ЊC),noted in148cases of K.pneumoniae liver ab-scess(92.5%)and18cases of polymicrobial liver abscess moniae liver abscess.Of the160patients with K.pneumoniae at Wenzhou Medical College on December 3, 2012 / Downloaded from1436Wang et al.CID 1998;26(June)liver abscess,19(11.9%)had metastatic foci other than the liver tube.One relapse was due to discontinuation of oral consolida-tion treatment.There were no specific risk factors in four of (table 1),including endophthalmitis (five patients),meningitis (four),lung abscess (four),psoas muscle abscess (two),brain the relapsed cases.Relapses of polymicrobial liver abscess were all due to the presence of inoperable intrahepatic stones abscess (one),lung and brain abscess (one),splenic abscess (one),and necrotizing fasciitis of the right leg (one).None or malignancies.Of 160patients with K.pneumoniae liver abscess,108of the 22patients with polymicrobial liver abscess had any detectable metastatic foci.(67.5%)had frank diabetes,12(7.5%)had impaired glucose tolerance,and 40(25%)were nondiabetic (table 2).The inci-The susceptibility of K.pneumoniae causing liver abscess in Taiwan was also a characteristic finding.The antimicrobial dence of impaired glucose metabolism was as high as 75%in this group.Of the patients with polymicrobial liver abscess,susceptibility pattern was the same in all 160cases,with resis-tance to ampicillin and ticarcillin/carbenicillin but susceptibil-one (4.5%)was diabetic,none had impaired glucose tolerance,and 22(95.5%)were nondiabetic (table 2).There was an obvi-ity to the other antibiotics including all the cephalosporins and aminoglycosides.Susceptibility to piperacillin was variable.ous difference in the incidence of of impaired glucose metabo-lism between patients with K.pneumoniae liver abscess and This pattern of susceptibility has remained unchanged since the onset of outbreak 15years ago.Although multiresistant those with polymicrobial liver abscess.CT of the whole abdomen was performed for all patients for strains of K.pneumoniae,whether nosocomial or community-acquired,are not unusual in Taiwan,these strains had not been evaluation of intra-abdominal abnormalities including common bile duct and intrahepatic duct stones,intra-abdominal infec-isolated previously from patients with primary K.pneumoniae liver abscess.tions,and malignancies.Of the 160patients with K.pneumo-niae liver abscess,only one (0.6%)had intrahepatic duct stones,Standard treatment in our hospital for both types of liver ab-scesses included pigtail catheter drainage by negative-pressure and none had intra-abdominal infections or malignancies (table 2).Seventeen (77.3%)of 22patients with polymicrobial liver suction and parenteral cephalosporins and aminoglycosides,ac-cording to susceptibility test results.For K.pneumoniae liver abscess had intrahepatic duct or common bile duct stones,four (18.2%)had intra-abdominal malignancies,and none had other abscess,cefazolin plus gentamicin was the standard therapy.We usually discontinued treatment with gentamicin after 2weeks to intra-abdominal infections (table 2).The rate of intra-abdomi-avoid nephrotoxicity but continued treatment with cefazolin for at least 3weeks or longer,depending on the clinical response and adequacy of abscess drainage.An oral cephalosporin was Table 2.Risk factors for Klebsiella pneumoniae liver abscess vs.administered for an additional 1–2months to prevent relapse.polymicrobial liver abscess at Veterans General Hospital-Kaohsiung,Taiwan,September 1990to June 1996.Pigtail catheter drainage was usually discontinued during the sec-ond week of hospitalization if culture of the drainage fluid yielded No.(%)of patients no growth,the patient was afebrile,and the daily amount of drainage was õ5mL for several days.With this treatment strat-K.pneumoniae Polymicrobial egy,the mortality (18of 160patients;11.3%)and relapse (7of liver abscess liver abscess Risk factor(n Å160)(n Å22)P value*160;4.4%)rates for K.pneumoniae liver abscess were low in contrast to those for polymicrobial liver abscess (9of 22;41.0%,Diabetes mellitus †120(75)1(4.5)õ.001and 9of 22;41.0%,respectively)(table 1).Frank diabetes108(67.5)1(4.5)...Causes of mortality among patients with K.pneumoniae liver Impaired glucose tolerance 12(7.5)0...abscess included fulminant sepsis (9of 18patients;50%),metasta-No diabetes40(25)21(95.5)...Intra-abdominal abnormalities 1(0.6)21(95.5)õ.001sis of infection to critical organs (4of 18;22.2%),rupture of the Biliary tree stone 1(0.6)17(77.3)...abscess (2of 18;11.1%),diabetic complications (1of 18;5.6%),Malignancy 04(18.2)...chronic obstructive pulmonary disease (1of 18;5.6%),and noso-Infection ial pneumonia (1of 18;5.6%).All cases of fulminant sepsis Steroid use00...were due to inadequate (4of 9)or delayed (5of 9)pigtail catheter Seropositive for HIV ‡0§0x...drainage.The prognosis for metastatic infection depended on the *P values were estimated by using the binomial test for two independent organs involved.Of the four fatal metastatic infections,two were samples.meningitis,one,a lung and brain abscess,and one,severe necrotiz-†Diabetes mellitus was defined as a random plasma glucose level of ú200mg/dL,a fasting plasma glucose level of ú140mg/dL,a fasting venous whole ing fasciitis.Rupture of the liver abscess before pigtail catheter blood glucose level of ú120mg/dL on more than one occasion,or an abnormal drainage is performed can induce peritonitis and result in death.oral glucose tolerance test,performed under standardized conditions,with In spite of pigtail catheter drainage and antimicrobial treatment,glucose levels at 2hours and in at least one other sample exceeding 200mg/dL.Impaired glucose tolerance was defined as glucose tolerance falling be-sepsis was the only cause of death among patients with polymi-tween normal and frank diabetes.crobial liver abscess.‡Determined with ELISAs for HIV-1and HIV-2.Seven cases of K.pneumoniae liver abscess relapsed after §n Å132.xn Å18.treatment.Two relapses were due to early removal of drainat Wenzhou Medical College on December 3, 2012/Downloaded from1437 CID1998;26(June)K.pneumoniae Liver Abscess in Taiwannal abnormalities in the polymicrobial group was95.5%,in As our series indicates,75%of patients with K.pneumoniaeliver abscess have diabetes or glucose intolerance.Diabetes is contrast to only0.6%in the K.pneumoniae group.HIV serostatus was determined for150patients by per-known to interfere with neutrophil chemotaxis and phagocyto-sis[8–11],but its influence on the function of macrophages, forming a single antibody measurement;these patients included132with K.pneumoniae liver abscess and18with polymicrob-including Kupffer’s cells,is still unknown.However,if thefunction of Kupffer’s cells is also impaired in diabetic patients, ial liver abscess.Sera were measured by using the WellcozymeRecombinant HIV1and2ELISAs(Murex Diagnostics,Dart-the preponderance of K.pneumoniae liver abscess cases inthis population could be explained by the escape of enteric ford,UK).All serological tests were negative(table2).Histor-ies of steroid use were obtained by reviewing the patients’K.pneumoniae from phagocytosis by Kupffer’s cells.Furtherstudies are required for validation of this hypothesis. charts;none of the patients had taken steroids within3monthsbefore the onset of K.pneumoniae liver abscess or polymicrob-In spite of the fact that diabetes is the most important predis-posing factor for K.pneumoniae liver abscess,we found that ial liver abscess.25%of cases occurred in patients without diabetes or glucoseintolerance,and we did notfind any correlation between the Discussionseverity of diabetes and the occurrence of K.pneumoniae liverabscess(authors’unpublished data).Therefore,impaired func-Primary K.pneumoniae liver abscess has rarely been re-ported in the literature;however,this condition is a prevalent tion of Kupffer’s cells may be a contributing factor,but unlikelythe sole factor,in the development of K.pneumoniae liver infectious complication in diabetic patients in Taiwan.In ourhospital,a maximum of50patients with liver abscess are ad-abscess in diabetic patients.The microbiological characteristics of K.pneumoniae are mitted to our infectious diseases wards annually.In our country,infectious diseases physicians are highly alert also subjects of interest.K.pneumoniae liver abscess has beenan endemic disease in Taiwan forú15years.During this pe-to the possibility of K.pneumoniae liver abscess.This diseaseis one of the foremost differential diagnoses considered for any riod,we have not detected any changes in the antibiogram ofK.pneumoniae strains isolated from patients with liver abscess, diabetic patient who presents with fever or for any patient witha blood culture positive for multisusceptible K.pneumoniae.i.e.,all strains have remained susceptible to all antibiotics testedexcept ampicillin and ticarcillin/carbenicillin.This phenome-A CT scan or gallium scan is routinely obtained for patientswith multisusceptible K.pneumoniae bacteremia to locate ab-non can be explained by the fact that K.pneumoniae that causesliver abscess is community acquired and is not naturally a scesses in the liver or other organs.K.pneumoniae liver abscess is a relatively benign disease multiresistant strain.On the other hand,this is not a plausiblehypothesis since antibiotics are freely used in many hospitals, that is associated with a low mortality rate,good clinical re-sponse,and low relapse rate.Standardized treatment,including pharmacies,and in traditional medicine and the livestock indus-try in Taiwan.pigtail catheter drainage and combination antimicrobial therapyfor2–3weeks,is highly plications such as se-Community-acquired infections caused by nosocomialstrains or multiresistant strains of K.pneumoniae are not un-vere sepsis,metastatic infection,and rupture of the abscess arenot uncommon and are usually associated with a poor progno-common.It is therefore surprising that strains of K.pneumoniaecausing liver abscess have persisted in our community forú15 sis.Some patients present with extrahepatic involvement alone;the conditions include meningitis,prostatic abscess,psoas mus-years without any changes in susceptibility patterns.It has beenobserved that patients septicemia due to multiresistant cle abscess,spinal abscess,septic arthritis,lung abscess,andsplenic abscess.Multisusceptible K.pneumoniae is now the K.pneumoniae,whether nosocomial or community acquired,do not develop liver abscesses.It remains to be determined if leading cause of primary gram-negative bacillary meningitis inour hospital;the annual incidence is15–20cases.Patients these strains have different biological properties despite thefact that they have the same biochemical characteristics. who recover from K.pneumoniae liver abscess after adequatetreatment usually remain free of relapse.The development of metastatic infection,a rare infectiouscomplication of gram-negative septicemia,is a characteristic In contrast to primary K.pneumoniae liver abscess,cases ofpolymicrobial liver abscess are usually secondary to biliary feature of K.pneumoniae liver abscess.In thefirst few casesof the outbreak in Taiwan,metastatic K.pneumoniae endoph-tract stones,malignancies,or intra-abdominal infections.Surgi-cal intervention is mandatory for cure,since standard therapy thalmitis was the principal diagnostic clue to the presence ofliver abscess[12,13].As the experience with K.pneumoniae for liver abscess will be ineffective in nearly one-half of cases.The rate of relapse is high despite successful treatment,since liver abscess increased,metastatic infections were detected inmany organs including the spleen,lungs,brain,meninges,para-bacteriologic eradication often fails because underlying malig-nancies or intrahepatic stones are present.meningeal space,prostate,bones,joints,and soft tissues[13].However,K.pneumoniae abscesses may occur alone in the Although K.pneumoniae liver abscess is a well-known dis-ease in Taiwan,many questions remain to be answered.The absence of liver abscess,with clinical presentations very similarto those of Staphylococcus aureus infection.According to our first is the association of this disease with diabetes mellitus. at Wenzhou Medical College on December 3, 2012 / Downloaded from1438Wang et al.CID 1998;26(June)unpublished data,K.pneumoniae has been one of the leading no different from other K.pneumoniae strains is another point requiring further clarification.The present report marks the causes of gram-negative meningitis,brain abscesses,bone and beginning of an effort to further the understanding of the patho-joint infections,splenic abscesses,and endophthalmitis over genesis of K.pneumoniae liver abscess.the past 15years.Clinical detection of K.pneumoniae liver abscess with meta-static infection is not difficult.In patients with uncomplicated ReferencesK.pneumoniae liver abscess,fever usually subsides after sev- 1.Rubin RH,Swartz MN,Malt R.Hepatic abscess:changes in clinical,bacteriologic and therapeutic aspects.Am J Med 1974;57:601–10.eral days of adequate pigtail catheter drainage and antimicrobial 2.Miedema BW,Dineen P.The diagnosis and treatment of pyogenic livertreatment.If defervescence is delayed,a gallium scan should abscesses.Ann Surg 1984;200:328–35.be obtained to detect the presence of metastatic infection.All 3.Wallack MK,Brown AS,Austrian R,et al.Pyogenic liver abscess second-isolates of K.pneumoniae from sites of metastatic infection ary to asymptomatic sigmoid diverticulitis.Ann Surg 1976;184:241–3.are multisusceptible strains,identical to those recovered from 4.Barnes PF,DeLock KM,Reynolds TN,et al.A comparison of amebicliver abscesses.and pyogenic abscess of the liver.Medicine (Baltimore)1987;66:Relapse of K.pneumoniae liver abscess after adequate treat-472–83.ment is rare.The liver has a dual blood supply:sterile arterial 5.Gyorffy EJ,Frey CF,Silva J Jr,et al.Pyogenic liver abscess.Diagnosticblood from the hepatic artery and venous blood from the gut,and therapeutic strategies.Ann Surg 1987;206:699–705.6.Sabbaj J.Anaerobes in liver abscess.Rev Infect Dis 1984;6(suppl 1):where transient bacteremia of the portal system is not unusual.S152–6.Therefore,the most probable source of K.pneumoniae in cases 7.Chang FY,Chou parison of pyogenic liver abscesses caused byof liver abscess is the gut.If this hypothesis is true,a high Klebsiella pneumoniae and non-K.pneumoniae pathogens.J Formos relapse rate would be expected,since conditions predisposing Med Assoc 1995;94:232–7.8.Tan JS,Anderson JL,Watanakunakorn C,Phair JP.Neutrophil dysfunctionto the formation of liver abscess do not change after treatment.in diabetes mellitus.J Lab Clin Med 1975;85:26–33.The low relapse rate in our series can only be explained by 9.Mowat AG,Baum J.Chemotaxis of polymorphonuclear leukocytes fromthe acquisition of immunity after infection.Determination of patients with diabetes mellitus.N Engl J Med 1971;284:621–7.the type of immunity involved,and its quantification,are topics 10.Chernew I,Braude AI.Depression of phagocytosis by solutes in concentra-for future studies.tions found in the kidney and urine.J Clin Invest 1962;41:1945–51.11.Eliashiv A,Olumide F,Norton L,Eiseman B.Depression of cell-mediatedK.pneumoniae liver abscess is an interesting infectious en-immunity in diabetes.Arch Surg 1978;113:1180–3.tity in Taiwan.The relation of this condition to race,environ-12.Liu YC,Cheng DL,Lin CL.Klebsiella pneumoniae liver abscess associ-ment,and the presence of diabetes mellitus,as well as its ated with septic endophthalmitis.Arch Intern Med 1986;146:1913–6.pathogenesis,remain uncertain.Whether the bacterial strains 13.Cheng DL,Liu YC,Yen MY,Liu CY,Wang RS.Septic metastatic lesionsof pyogenic liver abscess.Arch Intern Med 1991;151:1557–9.of K.pneumoniae found in liver abscesses are unique or areat Wenzhou Medical College on December 3, 2012/Downloaded from。
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（KLEBSIELLA PNEUMONIAE LIVER ABSCESS） KLA
重点资料
1
细菌性肝脓肿 肺炎克雷伯杆菌
KLA 与 NKLA KLA 与DM、治疗方法等
重点资料
2
肝脓肿
细菌性肝脓肿
肝w脓e肿lco是m细e菌to、us真e 菌the或s溶e P组o织we阿rP米oi巴nt原te虫mp等la多te种s, 微Ne生w物引 起C的o肝nt脏en化t d脓es性ig病n,变10。y肝ea脓rs肿ex分pe为ri三en种ce类型，其中细菌性 肝脓肿常为多种细菌所致的混合感染，约为80%，阿米巴 性肝脓肿约为10%，而真菌性肝脓肿低于10%。
中山医院对10年间197列肝脓肿患者结果进行分析， KLA与NKLA 肝右叶单发肝脓肿比率平均值均大于65%，两组间未
发现明显统计学差异（65.1%VS 69.6% ，P>0.05） 病灶大小：（73.85%VS73.77%）未发现明显统计学差异 是否含气腔：KLA明显高于NKLA(25.2%VS10.7%，P<0.001)
重点资料
10
肺炎克雷伯氏杆菌引起的气 性肝脓肿
请在此添加段落内容……
请在此添加段落内容…… 请在此添加段落内容……
重点资料
11
治疗方面
穿刺后是否使用药物冲洗（药物为甲硝唑和/庆大霉素） 76例患者中比较单独穿刺及穿刺加冲洗
白细胞计数降低
中性粒细胞百分比 降低
穿刺后脓肿缩小范 围
穿刺后体温平稳天 数
15
治疗方面
KLA
B超下经皮肝脓肿穿刺同时行药物冲洗与单独穿刺的疗效间， 未发现统计学差异； 穿刺后置管与否存在统计学差异，表现为穿刺置管一周后 复查B超，脓肿范围缩小较明显； 使用二联药物及三联药物治疗疗效之间比较，及二联药物 治疗时，甲硝唑加用喹诺酮类抗生素治疗疗效与三代头孢治 疗疗效之间比较，均未发现统计学意义。
对庆大霉素等氨基糖苷类抗生素、 头孢菌素类诸如头孢唑啉和头孢呋肟（西力欣）较敏感，氯霉 素及多粘菌素亦有一定疗效。
重点资料
4
流行病学（中国解放军医学院）
引起肝脓肿的肺炎克雷伯菌血清型以K1和K2为主，其中血清型K1共 分离到43株，占总数的42.57%；血清型K2共分离到37株，占总数的 36.63%，血清型K5没有分离到，其它血清型21株，占20.79%。 引起肝脓肿的肺炎克雷伯菌以高粘液性菌株为主，共90株，占所有 101例分离株的89.11%，其中血清型K1检出率为95%（41/43），血 清型K2检出率为92%（34/37），K1和K2组高粘液性表型相对较高。
肝功能无差异） 腔，增强期多
提示分隔强化
NKLA
腹部外科手术 腹痛(57,1)、乏
(17%)、恶性肿 瘤(2.8)、化放
力(46,4%)、肝 肿大(14.3)表现
5.76±0,3
疗(1.9)
更为明显
多为右叶单发 脓肿
重点资料
7
DM与KLA 39%的KLA合并DM
1、DM患者的葡萄糖降解率↓↓，为WBC提供能量功能↓，N趋化 功能缺陷，WBC杀菌活性↓↓； 2、长期高血糖有利于细菌生长；
重点资料
16
死亡率与迁徙性感染
死亡率：KLA<NKLA
迁徙性感染：KLA>NKLA
迁徙性感染：脑膜炎、肺炎、腹腔感 染
重点资料
17
过度使用氨比西林或阿莫西林增加肺炎克 雷伯菌肝脓肿风险
台湾台北 Yi-Tsung Lin
2013 -4 - 8
Journal of Infectious Diseases
单独穿刺（n=24） 5.12±0.71 17.72±0.41
22.67±2.37
5.79±1.24
穿刺+冲洗（n=52） 6.35±0.72 16.21±1.59
29.54±3.17
4.35±0.64
重点资料
12
治疗方面
穿刺后是否置管
单独穿刺 （n=24）
白细胞计数 降低
5.12±0.71
穿刺+置管 （n=24）
重点资料
14
复旦大学附属医院消化科（2010临床肝胆病杂志）
肝脓肿不同介入治疗方法 穿刺后药物冲洗并无统计学意义 穿刺+单独置管在缩小脓肿直径方面明显优于单独穿刺组及穿刺
+冲洗组（34.38±3.25VS22.67±2.37VS24.45±3.17） 使用二联抗生素及三联抗生素差异无统计学意义
重点资料
重点资料
5
12年中山医院
KLA
伴发基础疾病 临床表现
实验室检查 影像学检查
糖尿病(53.8%)、 脂肪肝(16%)
（胆道疾病、 发热、寒战无 肝硬化、乙型 明显差异
肝炎合并症无 明显差异）
空腹血糖均值 多为右叶单发
较高
脓肿
7.84±0.36 CT：脓肿边缘
（白细胞计数、 更为模糊，更
中性粒细胞、 大机会存在气
氨比西林和阿莫西林的治疗改变了肠内菌群的生态平衡，可能导致 肺炎克雷伯菌的过度增殖。研究发现，近期 30 天内使用氨比西林 和阿莫西林增加发生肺炎克雷伯菌肝脓肿的风险。
重点资料
18
Klebsiella pneumoniae liver abscess and endophthalmitis
细菌性肝脓肿的病原体中，以肠道来源菌群为主，近10年 间，各项研究发现，肺炎克雷伯杆菌(59.8%)已取代大肠 埃希菌、绿脓杆菌占据了主要地位。
重点资料
3
肺炎克雷伯杆菌
克雷伯氏菌属为肠杆菌 科中一类有荚膜的革兰氏 阴性杆菌，兼性厌氧，导致 化脓的机会是革兰氏阳性菌 的1/4-1/5，导致患者的死亡 率确是其2倍。
3、DM患者易有血管病变，大、中、微血管结构和功能异常， 局部血液和循环障碍，周围组织供养减少。重点资料 Nhomakorabea8
DM患者肝脓肿（ ） 中华临床感染病杂志
抗感染同时，应控制好血糖，急性感 染期与围手术期应静脉/皮下注射胰 岛素
发病前从未用过胰岛素患者应坚 持胰岛素治疗直至脓肿消失
重点资料
9
影像学诊断方面
7.68±1.09
穿刺后一周B超显示脓肿减少更明 显
中性粒细胞 百分比降低
17.72±0.41
15.20±2.18
穿刺后脓肿 缩小范围
22.67±2.37
34.38±3.25
穿刺后体温 平稳天数
5.79±1.24
6.75±1.72
重点资料
13
治疗方面
使用二联抗生素或三联抗生素（甲硝唑/奥硝唑，喹诺酮类，二、 三代头孢） 分别比较了仅穿刺组、穿刺+冲洗组、穿刺+置管组均发现使用二联 抗生素及三联抗生素无明显差异