Logistic early warning scores to predict death, cardiac arrest or unplanned intensive care unit re-admission after cardiac surgery.

NHS England recently mandated that the National Early Warning Score of vital signs be used in all acute hospital trusts in the UK despite limited validation in the postoperative setting. We undertook a multicentre UK study of 13,631 patients discharged from intensive care after risk-stratified cardiac surgery in four centres, all of which used VitalPACTM to electronically collect postoperative National Early Warning Score vital signs. We analysed 540,127 sets of vital signs to generate a logistic score, the discrimination of which we compared with the national additive score for the composite outcome of: in-hospital death; cardiac arrest; or unplanned intensive care admission. There were 578 patients (4.2%) with an outcome that followed 4300 sets of observations (0.8%) in the preceding 24 h: 499 out of 578 (86%) patients had unplanned re-admissions to intensive care. Discrimination by the logistic score was significantly better than the additive score. Respective areas (95%CI) under the receiver-operating characteristic curve with 24-h and 6-h vital signs were: 0.779 (0.771-0.786) vs. 0.754 (0.746-0.761), p < 0.001; and 0.841 (0.829-0.853) vs. 0.813 (0.800-0.825), p < 0.001, respectively. Our proposed logistic Early Warning Score was better than the current National Early Warning Score at discriminating patients who had an event after cardiac surgery from those who did not.

Analysis of the gut microbiota in alopecia areata: identification of bacterial biomarkers.

BACKGROUND: Alopecia areata is a T-cell-mediated autoimmune disease with an unknown etiopathogenesis. Gut microbiota has been revealed as a key modulator of systemic immunity. OBJECTIVE: To determine whether patients affected by alopecia universalis present differences in gut bacteria composition compared with healthy controls and investigate possible bacterial biomarkers of the disease. METHODS: We conducted a cross-sectional study that involved 15 patients affected by alopecia universalis and 15 controls. Gut microbiome of the study subjects was analysed by sequencing the 16SrRNA of stool samples. We searched for bacterial biomarkers of alopecia universalis using the linear discriminant analysis effect size (LEFse) tool. RESULTS: In total, 30 study subjects (46.6% female; mean [SD] age, 40.1 [9.8] years) were enrolled. Neither alpha (Shannon diversity index 5.31 ± 0.43 vs. 5.03 ± 0.43, P 0.1) or beta diversity (ADONIS P value: 0.35) of gut microbiota showed statistically significant differences between cases and controls. In patients affected with alopecia, we found an enriched presence (LDA SCORE > 2) of Holdemania filiformis, Erysipelotrichacea, Lachnospiraceae, Parabacteroides johnsonii, Clostridiales vadin BB60 group, Bacteroides eggerthii and Parabacteroides distasonis. A predictive model based on the number of bacterial counts of Parabacteroides distasonis and Clostridiales vadin BB60 group correctly predicted disease status in 80% of patients (AUC 0.804 (0.633-0.976), P 0.004). CONCLUSION: Alopecia universalis does not seem to affect broadly gut microbiota structure. Bacterial biomarkers found associated with the disease (Holdemania filiformis, Erysipelotrichacea, Lachnospiraceae, Parabacteroides johnsonii, Eggerthellaceae, Clostridiales vadin BB60 group, Bacteroides eggerthii and Parabacteroides distasonis) should be further studied as they could be involved in its pathophysiology or be used as diagnostic tools.

Evaluation of kidney function in HIV-infected patients receiving an antiretroviral regimen containing one or two inhibitors of the tubular secretion of creatinine.

OBJECTIVES: The aim of this study was to determine the evolution of renal function in patients receiving one or two inhibitors, according to different baseline factors. Some antiretroviral drugs such as rilpivirine (RPV), dolutegravir (DTG), or cobicistat (COBI), interact with the tubular secretion of creatinine, but there are no data about their impact in renal function evaluation in patients with renal disease or when these drugs are used concomitantly. METHODS: A prospective cohort study was carried out in HIV-infected patients who switched to a dual regimen including DTG, RPV or darunavir/COBI, separately or in combination. The primary endpoint was the evolution of the serum creatinine-based estimated glomerular filtration rate (eGFR-scr). A control group not receiving any transporter inhibitor was included. RESULTS: A total of 288 patients on different dual regimens were included (DTG + RPV, 92; DTG + darunavir/COBI, 23; DTG, 26; COBI, 19; control group, 128). In patients receiving two transporter inhibitors, eGFR-scr decreased by a mean of -8.4 mL/min/1.73 m2 , similar to that observed with the separate use of DTG or COBI (mean of both groups, -8.6 mL/min/1.73 m2 ), while eGFR-scr improved in the control group. Similar evolution of proteinuria and tubular dysfunction was observed in all the groups, and there were no significant changes in the cystatin C-based eGFR. Mean eGFR-scr change inversely correlated with baseline eGFR-scr value (r = -0.39; P < 0.01), with a lower eGFR-scr decrease in patients with chronic kidney disease. CONCLUSIONS: Similar eGFR-scr decreases were observed in patients using different antiretroviral drugs inhibiting the tubular transport of creatinine, separately or in combination, with no alterations in proteinuria or cystatin C-based eGFR. The lack of additional changes when the drugs were used in combination, and the lower impact in cases of previous chronic kidney disease, suggest that there are compensatory mechanisms for creatinine secretion.

Measurement of extravascular lung water to diagnose severe reperfusion lung injury following pulmonary endarterectomy: a prospective cohort clinical validation study.

The measurement of extravascular lung water is a relatively new technology which has not yet been well validated as a clinically useful tool. We studied its utility in patients undergoing pulmonary endarterectomy as they frequently suffer reperfusion lung injury and associated oedematous lungs. Such patients are therefore ideal for evaluating this new monitor. We performed a prospective observational cohort study during which extravascular lung water index measurements were taken before and immediately after surgery and postoperatively in intensive care. Data were analysed for 57 patients; 21 patients (37%) experienced severe reperfusion lung injury. The first extravascular lung water index measurement after cardiopulmonary bypass failed to predict severe reperfusion lung injury, area under the receiver operating characteristic curve 0.59 (95%CI 0.44-0.74). On intensive care, extravascular lung water index correlated most strongly at 36 h, area under the receiver operating characteristic curve 0.90 (95%CI 0.80-1.00). Peri-operative extravascular lung water index is not a useful measure to predict severe reperfusion lung injury after pulmonary endarterectomy, however, it does allow monitoring and measurement during the postoperative period. This study implies that extravascular lung water index can be used to directly assess pulmonary fluid overload and that monitoring patients by measuring extravascular lung water index during their intensive care stay is useful and correlates with their clinical course. This may allow directed, pre-empted therapy to attenuate the effects and improve patient outcomes and should prompt further studies.

Decreasing prevalence of HCV coinfection in all risk groups for HIV infection between 2004 and 2011 in Spain.

While hepatitis C virus (HCV) infection seems to be expanding among HIV-infected men who have sex with men (MSM), the rate of coinfection in intravenous drug users (IDU) is assumed to remain constant. We evaluated the serial prevalence of HIV/HCV coinfection across all risk groups for HIV infection in Spain. We used data from 7045 subjects included in the multicentre, prospective Spanish Cohort of Adult HIV-infected Patients (CoRIS) between 2004 and 2011. We analysed risk factors for HIV/HCV coinfection by logistic regression analyses. The prevalence of HIV/HCV coinfection decreased from 25.3% (95% CI, 23.1-27.5) in 2004-2005 to 8.2% (95% CI, 6.9-9.5) in 2010-2011. This trend was consistently observed from 2004 to 2011 among all risk groups: IDU, 92.4% to 81.4%; MSM, 4.7% to 2.6%; heterosexual men, 13.0-8.9%; and heterosexual women, 14.5-4.0% (all P < 0.05). Strongest risk factors for HIV/HCV coinfection were IDU (OR, 54.9; 95% CI, 39.4-76.4), birth decade 1961-1970 (OR, 2.1; 95% CI, 1.1-3.7) and low educational level (OR, 2.4; 95% CI, 1.6-3.5). Hence, the prevalence of HIV/HCV coinfection decreased in Spain between 2004 and 2011. This decline was observed across all risk groups and is likely to be explained by a declining burden of HCV in the general population.

The CD4:CD8 ratio is associated with markers of age-associated disease in virally suppressed HIV-infected patients with immunological recovery.

OBJECTIVES: Inversion of the CD4:CD8 ratio (< 1) has been identified as a hallmark of inmmunosenescence and an independent predictor of mortality in the general population. We aimed to assess the association between the CD4:CD8 ratio and markers of age-associated disease in treated HIV-infected patients with good immunovirological response. METHODS: A cross-sectional analysis was conducted in 132 HIV-infected adults on antiretroviral therapy (ART), with plasma HIV RNA < 50 HIV-1 RNA copies/mL for at least 1 year, CD4 count > 350 cells/µL and age < 65 years. We analysed the associations between the CD4:CD8 ratio and subclinical atherosclerosis [assessed using carotid intima-media thickness (IMT)], arterial stiffness [assessed using the augmentation index (AIx)], the estimated glomerular filtration rate (eGFR), muscle wasting and sarcopenia [assessed using appendicular lean mass/height(2) (ALM) measured by dual-energy X-ray absorptiometry (DEXA)]. RESULTS: CD4:CD8 ratio inversion was associated with higher IMT, lower eGFR and lower ALM (all values P < 0.05), but not with AIx. In multivariate analyses adjusted for age, sex, hypertriglyceridaemia, tobacco use and cumulative ART exposure, inversion of the CD4:CD8 ratio was independently associated with higher IMT [odds ratio (OR) 2.9; 95% confidence interval (CI) 1.2-7.1], arterial stiffness (OR 4.8; 95% CI 1.0-23.5) and lower eGFR (OR 5.2; 95% CI 1.0-64.4), but not sarcopenia (OR 0.7; 95% CI 0.2-2.7). These associations persisted when models were applied to subjects with nadir CD4 counts > 200 cells/µL and those with CD4 counts > 500 cells/µL. CONCLUSIONS: The CD4:CD8 ratio in treated HIV-infected subjects with good immunovirological response is independently associated with markers of age-associated disease. Hence, it might be a clinically useful predictor of non-AIDS-defining conditions.

[Incidence of prolonged grief disorder in relatives of patients who die during or after admission in Intensive Care Unit]. / Incidencia del trastorno por duelo prolongado en los allegados de pacientes fallecidos durante o tras ingreso en la Unidad de Cuidados Intensivos.

OBJECTIVES: To determine the incidence of «Prolonged Grief Disorder¼ from one year after the death of a relative admitted to the Intensive Care Unit. MATERIAL AND METHODS: A cross-sectional, longitudinal follow-up study was conducted in a general ICU of a reference hospital. The relatives were evaluated approximately one year after the death using the «Consensus Criteria for Prolonged Grief Disorder¼ as a tool. The prevalence between the first and second years was determined. RESULTS: A total of 151 relatives of patients who died in ICU were included. The follow-up was carried out 22.1±5.3 months after the death. Eleven relatives (10.3%) fulfilled the «Consensus Criteria for Prolonged Grief Disorder¼. Of all the grieving relatives, those identified with prolonged grief disorder are the ones who most often require psychological/psychiatric support. CONCLUSIONS: In a sample of close relatives of patients who died in ICU, a significant minority fulfilled the criteria for «Prolonged Grief Disorder¼ 1-2 years after the death. This condition, which is often overlooked, and could require some kind of psychological treatment, should be taken into consideration.

[Severe thrombocytopenia on admission to the intensive care unit in patients with multiple organ failure]. / Trombocitopenia grave al ingreso en una unidad de cuidados intensivos en pacientes con disfunción multiorgánica.

OBJECTIVE: To evaluate the frequency of severe thrombocytopenia (STCP) (≤ 50,000/µl) in the first 24 hours in patients with multiple organ dysfunction syndrome, and the factors that influence its occurrence. DESIGN: A retrospective, observational study. AREA: Medical-surgical intensive care unit (ICU). Tertiary hospital. PATIENTS: Those with failure of at least two organs, according to SOFA criteria, with the exclusion of neurological and traumatologic critical cases. VARIABLES: Medical history, regular medication, baseline functional status, demographic variables, severity scores in ICU, multiple-organ failure data, course in ICU and main hospital data. RESULTS: A total of 587 patients were included; 6.3% (37 patients) presented with STCP during the first day of admission; 64.6% were men; SOFA 8 (5-10); APACHE II 18 (13-24); APACHE IV 59 (46-73); 32.5% were surgical patients. A total of 79.9% subsequently needed mechanical ventilation, and 71.4% required vasoactive drugs. Overall stay in ICU: 4 (2-10) days, main hospital stay 18 (9-35) days. A total of 29.2% died in the ICU; 11.7% developed STCP during admission to the ICU. Multivariate analysis found the main determining factors in the occurrence of thrombocytopenia on admission to be: history of hospitalization in the last year, albumin and bilirubin levels, and sepsis. CONCLUSION: The prevalence of STCP among critical patients was 6.3%. Its occurrence was associated with albumin and bilirubin levels, sepsis, and with patient admittance in the last year.

[Nebulized colistin treatment of multi-resistant Acinetobacter baumannii pulmonary infection in critical ill patients]. / Utilización de la colistina nebulizada en la colonización e infección respiratoria por Acinetobacter baumannii en pacientes críticos.

OBJECTIVE: To analyze the efficacy of nebulized colistin in the microbiological eradication and clinical improvement of patients with pulmonary infection by multi-resistant Acinetobacter baumannii (MAB). DESIGN: A retrospective study. SETTING: Intensive Care Unit of a Tertiary hospital. PATIENTS: Hospitalized patients on invasive mechanical ventilation with positive MAB cultures of the airway. INTERVENTIONS: All received treatment with colistin (CL). Nosocomial pneumonia (NP) or Tracheobronchitis (TB) was determined according to routine criteria and colonization (CO) was determined in the case of a positive culture in the absence of infection criteria. Three groups of patients were defined: those treated with nebulized CL, those treated with IV CL and those treated with IV CL plus nebulized CL. MAIN MEASUREMENTS: Baseline characteristics. Microbiological eradication and clinical recovery were evaluated according to routine criteria. RESULTS: 83 patients were studied, 54 of whom were treated, with the following diagnoses: 15 (27.8%) with NP, 16 (29.6%) with TB and 23 patients (42.6%) with CO. Nebulized CL was used in 36 patients (66.7%): 66.7% of which for CO, 33.3% in treatment for TB and in no case of NP. In 61.1% of the patients, IV CL was used: 22.2% of which for CO, 38.9% for TB and 38.9% in NP. The combination of IV CL and nebulized CL was used in 15 patients (27.8%): 5 patients (33.3%) CO, 2 patients (13.3%) TB and 8 patients (53.3%) NP. Microbiological eradication was achieved in 32 patients (59.3%), with the following distribution: 8 (47.1%) with IV CL, 15 (83.3%) with nebulized CL and 9 patients (69.2%) with a combination of IV CL and nebulized CL. Clinical recovery was achieved in 42 patients (77.8%): 12 (80%) with IV CL, 18 (94.7%) with nebulized CL and 12 (85.7%) with a combination of nebulized and IV CL. These differences were not significant. In the group of patients with infection due to TB and NP (31 patients, 57.4%), microbiological eradication was achieved in 5 patients (100%) treated with nebulized CL and in 6 of the 9 patients (42.9%) treated with IV CL, the difference being significant (P<.05). Clinical recovery in this group was 100% (6 patients) treated with nebulized CL and 75% (9 of the 12 patients) in the IV CL group. This difference was not significant. CONCLUSIONS: Our study suggests that treatment with colistin in patients with pulmonary infection with multi-resistant Acinetobacter baumannii could be more efficient if it were to be administrated solely nebulized or in combination with IV colistin rather than administered solely intravenously.

Systemic acidemia impairs cardiac function in critically Ill patients.

BACKGROUND: Acidemia, is associated with reduced cardiac function in animals, but no studies showing an effect of acidemia on cardiac function in humans are reported. In the present study, we examined the effect of acidemia on cardiac function assessed with transpulmonary thermodilution technique with integrated pulse contour analysis (Pulse Contour Cardiac Output, PiCCO™) in a large cohort of critically ill patients. METHODS: This was a prospective multicenter observational cross-sectional study of 297 patients from 6 intensive care units in London, England selected from all patients admitted consecutively between May 2018 and March 2019. Measurements of lowest plasma pH and concurrent assessment of cardiac function were obtained. FINDINGS: There was a significant difference between two pH categories (pH ≤ 7.28 vs. pH > 7.28) for the following variables of cardiac function: SVI (difference in means 32.7; 95% CI: 21 to 45 mL/m2; p < 0.001); GEF (18; 95% CI: 11 to 26%; p < 0.001), dPmax (-331; 95% CI: -510 to -153 mmHg/s; p = 0.001), CFI (0.7; 95% CI: 0.2 to 1.3 1/min; p = 0.01) and CPI (0.09; 95% CI: 0.03 to 0.15 W/m2; p < 0.001). However, there was no significant difference in CI (0.13; 95% CI: -0.20 to 0.47 L/min/m2; p = 0.12) between the pH categories. Also, a significant relationship was found between the quantitative pH and the following variables: SVI (132; 95% CI: 77 to 188 mL/m2; p < 0.001), GEF (74.7; 95% CI: 37.1 to 112.4%; p < 0.001), dPmax (-1587; 95% CI: -2361 to -815 mmHg/s; p < 0.001), CFI (3.5; 95% CI: 0.9 to 6.1 /min; p = 0.009), CPI (0.62; 95% CI: 0.36 to 0.88 W/m2; p < 0.001) and CI (regression coefficient 1.96; 95% CI:0.45 to 3.47 L/min/m2; p = 0.01). INTERPRETATION: Acidemia is associated with impaired cardiac function in seriously ill patients hospitalized in the intensive care unit supporting the potential value of early diagnosis and improvement of arterial pH in these patients. FUNDING: The study was partially supported by unrestricted funds from the UCLA School of Medicine.

TP53 and EGFR mutations in combination with lifestyle risk factors in tumours of the upper aerodigestive tract from South America.

Cancers of the upper aerodigestive tract [(UADT): oral cavity, pharynx, larynx and oesophagus] have high incidence rates in some parts of South America. Alterations in the TP53 gene are common in these cancers. In our study, we have estimated the prevalence and patterns of TP53 mutations (exons 4-10) in 236 UADT tumours from South America in relation to lifestyle risk factors, such as tobacco smoking and alcohol drinking. Moreover, we have conducted a pilot study of EGFR mutations (exons 18-21) in 45 tumours from the same population. TP53 mutation prevalence was high: 59% of tumours were found to carry mutant TP53. We found an association between TP53 mutations and tobacco smoking and alcohol drinking. The mutation rate increased from 38% in never-smokers to 66% in current smokers (P-value for trend = 0.09). G:C>T:A transversions were found only in smokers (15%). Alcohol drinkers carried more G:C>A:T transitions (P = 0.08). Non-exposed individuals were more probable to carry G:C>A:T transitions at CpG sites (P = 0.01 for never-smokers and P < 0.001 for never-drinkers). EGFR mutations were found in 4% of cases. Inactivation of TP53 by mutations is a crucial molecular event in the UADT carcinogenesis and it is closely related to exposure to lifestyle risk factors. EGFR mutations do not appear to be a common event in UADT carcinogenesis in this population.

Possible heterochromatin horizontal spread through non-homologous chromosome associations in pachytene chromocenters of Ctenomys Rodents.

Heterochromatin patterns were analyzed in the genus Ctenomys from Uruguay which exhibits high karyotype variability. Different amounts and localizations of heterochromatin were observed in species and populations analyzed. While species as C. rionegrensis presented heterochromatic arms in all the chromosomes of the karyotype, other species like C. torquatus showed only few chromosomes with pericentric heterochromatin. At the pachytene stage, bivalents merge in densely stained chromocenters. We detected in these chromocenters the typical highly repeated DNA of this genus after in situ hybridization, the M31 chromodomain through immunofluorescence as well as dense Giemsa staining after C-banding. In species that present low amounts of heterochromatin, only 1 or 2 chromocenters were observed in which bivalents merge as observed in C. rionegrensis. After BRCA1 immunodetection we observed in early pachytene cells positive spots located over heterochromatic chromocenters that strongly suggest heterochromatic DNA repair. Mechanical stress mainly due to increasing chromatin compactness before metaphase I might be a mechanism to spread heterochromatin between different chromosomes within a karyotype.

The arterial blood gas algorithm: Proposal of a systematic approach to analysis of acid-base disorders. / El algoritmo de la gasometría arterial: propuesta de un enfoque sistemático para el análisis de los trastornos del equilibrio ácido-base.

Abnormalities in the acid-base balance are common clinical problems and can have deleterious effects on cellular function and be a clue to various disorders. Therefore, it is important for the clinician to make a precise diagnosis of the acid-base disorder(s) present for a proper treatment. Three approaches have been proposed to evaluate acid-base disorders: a bicarbonate-centric approach; the Stewart approach, and the base excess approach. Although the latter two have many adherents, we will only discuss the bicarbonate-centric approach. This approach is simpler to utilize at the bedside, has a physiological evaluation of the acid-base disorder, presents an easily understandable approach to assess severity, and provides a more solid foundation for the development of effective therapies. Therefore, the following discussion will be limited to an examination of this approach. In this case-centric review, important new concepts will be introduced first; their benefits and limitations discussed; and then their utilization to analyze actual cases will be shown. A systematic approach algorithm that incorporates these new concepts has been generated and will be highlighted.

Smoking cessation in HIV patients: rate of success and associated factors.

BACKGROUND: Smoking is the modifiable cardiovascular (CV) risk factor that contributes most to causing premature CV disease. Prevalence of smoking in patients with HIV infection is double that of the general population. OBJECTIVES: To determine the rate of patients succeeding in quitting smoking after 12 months, factors associated with this success, and the characteristics of tobacco consumption and nicotine dependence. METHODS: Longitudinal descriptive study. Three hundred and sixty-eight HIV-infected patients were interviewed. Smokers in Prochaska's stage of action began a programme to quit smoking. We registered the variables related to tobacco consumption and the level of success of cessation. RESULTS: 63.9% of the patients were active smokers and 14% of them began the cessation programme. Average motivation for cessation was 7.8 +/- 1.4 (Richmond) and nicotine dependence rate 5.5 +/- 3.0 (Fagerström). After 1 year, 25% had quit smoking. Those patients who stopped smoking presented a higher motivation level (8.8 +/- 1.3 vs. 7.5 +/- 1.5, P=0.048). Cessation significantly reduced their CV risk at 12 months [2.5 [interquartile range (IQR) 2.0-5.2] vs. 1.7 [IQR 1.0-3.5], P=0.026]. CONCLUSIONS: The prevalence of smokers in our population of HIV-infected patients was 63.9%. Only 14% began a smoking cessation programme. Twelve months after a programme to quit smoking, cessation rate was 25%; this was influenced mostly by the level of motivation of the patient.

[Long-term results of patients with congenital diaphragmatic hernia]. / Resultados a largo plazo de pacientes con hernia diafragmáitica congénita.

OBJECTIVE: Introduction of advanced therapeutic modalities for diaphragmatic congenital hernia (CDH) has allowed to reach considerable improvements in survival rate. Nevertheless, there are few studies which analyze the clinical evolution of the long-term survivors. The aim of this work is to analyze the outcomes of the patients with CDH in our hospital. METHODS: Fifty-five neonates with CDH were treated in our center between 1998 and 2005. We included in the study those patients that were alive at the moment of first hospital discharge (72%; n=40 patients). ECMO therapy was needed in 6 of them during neonatal treatment. A descriptive transverse review of the clinical record as well as a telephonic interview to the parents was performed for the respiratory, cardiological, digestive and neurological conditions, following standard diagnostic studies in every case. The mean age of the children in the moment of the study was 4.2 years (1-9). RESULTS: The 8.3% of the children needed domiciliary oxygen therapy during a maximum of 3 months in all the cases. 22% of the cases suffered from respiratory problems, being bronchiolitis and pneumonia the most frequent diagnoses. Only a patient developed asthma. The gastroesophageal reflux is the most frequent long-term condition (47%), but only 8.3% needs surgical treatment. Regarding to cardiological problems, 14% developed pulmonary hypertension, being slight - moderate in all the cases but in one case who was the only deceased of the series. Regarding to neurological problems only 1 patient developed serious alterations (brain paralysis), having suffered a hemorrhage parenquimatosa during the treatment with ECMO. No other patient presents motor, visual nor auditory alterations in the development, last mild alteration in language (4 patients). Differences do not exist with the group of patients that did not need ECMO during the treatment in cardiological and digestive complications, being higher percentage with respiratory problems. CONCLUSION: In our sample only 2 patients present serious sequels (5%). Of this preliminary study we can conclude that the comorbility in the CDH is very low having these patient a good development and good quality of life.

Antibiotic-resistant hypervirulent Klebsiella pneumoniae causing community- acquired liver abscess: an emerging disease.

We report a case of a patient with fatal community-acquired pyogenic liver abscess (CA-PLA) caused by multi drug-resistant, hypervirulent, Klebsiella pneumoniae (mdrhvKP). HvKP causing PLA has been described in East and South East Asia and it is recognized as an emerging infection worldwide. The syndrome is characterized by cryptogenic liver abscess formation without a previous history of hepatobiliary or colonic disease and metastatic spread of infection via the bloodstream to distant sites, including lungs, central nervous system and other organ systems. Diabetes mellitus is a recognized risk factor. Most previously reported cases have involved antibiotic susceptible strains of hvKP although reports of bloodstream infections caused by resistant strains, including carbapenemase producers, are increasing. Our report highlights the need for awareness of this devastating infection in patients presenting with sepsis and liver abscess without underlying hepatobiliary or colonic disease.