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

BACKGROUND AND AIM: Cholangitis, bacteremia, and pyogenic liver abscess (PLA) can be often caused by intrahepatic bile ducts stone (IBDS), which is endemic to South-East Asia. The association between IBDS and cholangiocarcinoma has been well recognized. Concomitant cholangiocarcinoma in the PLA related to IBDS is often missed. METHODS: A case-control study consisting of 64 patients with PLA related to IBDS and 256 control patients with PLA not related to IBDS was used to investigate clinical features of PLA and incidence of concomitant cholangiocarcinoma in patients with PLA related to IBDS. RESULTS: The main imaging manifestations of PLA related to IBDS was cystic-solid lesions and solid lesions. Of seven patients (10.9%) with pathology-proven cholangiocarcinoma in the same area of PLA related to IBDS among 64 patients, only two patients were initially diagnosed as having concomitant cholangiocarcinoma by biopsy, and other five patients diagnosed as acute inflammatory lesion. Within 60 days after onset, the infection-related death rate and recurrence rate in patients with PLA related to IBDS were 12.9% and 20.3%, respectively, whereas in patients with PLA not related to IBDS were 3.9% and 3.1%, respectively. Only 25% of patients with PLA related to IBDS underwent surgery after admission. The main pathogens in PLA patients related to IBDS were Escherichia coli and extended-spectrum beta-lactamase-producing Enterobacteriaceae. CONCLUSIONS: The imaging manifestations of PLA related to IBDS often present cystic-solid or solid lesions. PLA related to IBDS is characterized by high rate of recurrence and infection-related death, difficulty in diagnosis of concomitant cholangicarcinoma.

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

BACKGROUND & AIMS: Little is known about aetiology and morbidity and clinical characteristics of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. METHODS: An analysis between pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates and those caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae was performed. RESULTS: Among 817 pyogenic liver abscess patients, there were 176 patients (21.5%) with pyogenic liver abscess of biliary origin, and 67 pyogenic liver abscess patients (8.2%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates (mainly Escherichia coli and Klebsiella pneumoniae). Of 176 pyogenic liver abscess patients related to biliary disorders, there were 48 pyogenic liver abscess patients (27.3%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Within 67 pyogenic liver abscess patients caused by Enterobacteriaceae expressing extended-spectrum beta-lactamases, the occurrences of 48 pyogenic liver abscess patients (71.6%) were associated with biliary disorders. When compared with pyogenic liver abscess patients caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae, there were significantly greater incidences of polymicrobial infections, bacteremia, pulmonary infection, recurrence and death in pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Carbapenems remain mainstay drugs against extended-spectrum beta-lactamase-producing E. coli and K. pneumoniae. Independent risk factors for occurrence of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae were biliary disorders including extra- and intrahepatic cholangiolithiasis and an abnormal bilioenteric communication between bile and gut, a treatment history of malignancy such as operation and chemotherapy, pulmonary infection, and diabetes mellitus. CONCLUSIONS: Pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates mainly occurs in patients with biliary disorders or with a treatment history of malignancy. The mainstay of treatment remains carbapenems in combination with adequate aspiration or drainage.

Risk factors for pneumonia caused by multidrug-resistant Gram-negative bacilli among liver recipients.

Pneumonia caused by multidrug-resistant (MDR) Gram-negative bacilli is associated with a higher mortality rate. The appropriate empiric therapy is based on the understanding of local etiology and MDR pattern. This study was to evaluate the spectrum of Gram-negative bacilli, MDR rate, risk factors and mortality in 475 liver transplantation (LT) recipients. In the first six months after LT, the incidence of bacterial pneumonia was 21.3% (101/475). The overall infectious incidence during the first post-transplant month was 80.2%. The most frequent pneumonia isolates were Enterobacteriaceae, Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus. Gram-negative bacilli accounted for 69.6% of all pneumonia pathogens. Of the main 124 Gram-negative bacilli isolates, MDR rate was 58.9%. Four risk factors for post-LT pneumonia caused by MDR Gram-negative bacilli were LT candidates with grade II-IV encephalopathy (OR 2.275, 95%CI 1.249-4.124, p = 0.006), prolonged duration of endotracheal intubation (OR 8.224, 95%CI 4.276-15.815, p = 0.013), tracheostomy (OR 4.929, 95%CI 1.099-18.308, p = 0.027) and post-LT episode(s) of reoperations (OR 10.597, 95%CI 3.726-30.134, p < 0.001). MDR Gram-negative bacterial pneumonia-related mortality was significantly higher than that because of antibiotic-susceptible bacilli (45.6% vs. 11.4%, p = 0.010). Our data suggest that pneumonia caused by MDR Gram-negative bacilli after LT is common, and associated with the severity of underlying disease, prolonged mechanical ventilation and upper abdominal surgery.