Invasive liver abscess syndrome caused by Klebsiella pneumoniae
- Wen-Liang Yu, MD
Wen-Liang Yu, MD
- Associate Professor of Medicine
- Chi-Mei Medical Center, Taiwan
- Yin-Ching Chuang, MD
Yin-Ching Chuang, MD
- Professor of Medicine
- Chi-Mei Medical Center, Taiwan
Klebsiella pneumoniae can produce infection at a variety of sites, with the risk being increased in patients with impaired host defenses (eg, diabetes mellitus, alcoholism, malignancy, chronic obstructive pulmonary disease, and glucocorticoid therapy). K. pneumoniae is also associated with a community-acquired primary invasive liver abscess syndrome. In addition to liver abscess, some patients develop metastatic infection at other sites.
Issues related to the K. pneumoniae invasive liver abscess syndrome will be reviewed here. The epidemiology, clinical features (including the general principles of diagnosis and treatment), microbiology, and pathogenesis of K. pneumoniae infection are discussed separately. (See "Clinical features, diagnosis, and treatment of Klebsiella pneumoniae infection" and "Microbiology and pathogenesis of Klebsiella pneumoniae infection".)
K. pneumoniae primary liver abscess has been variably defined in the literature. In one study, for example, primary liver abscess was defined as a K. pneumoniae liver abscess occurring in the absence of predisposing intraabdominal factors, such as hepatobiliary disease, colorectal disease, or a history of intraabdominal surgery or trauma . In other studies, it has been defined by a monomicrobial K. pneumoniae isolate, while polymicrobial liver abscess was usually secondary to hepatobiliary disease or intraabdominal infection [2,3].
We prefer to define K. pneumoniae primary liver abscess (KLA) as liver abscess that occurs in the absence of hepatobiliary disease. Almost all of these infections are monomicrobial [3-5]. Although this topic highlights virulent strains of K. pneumoniae that have the capacity to invade a healthy liver without predisposing anatomical abnormalities, the rare possibility of concurrent colorectal disease cannot be excluded, as routine colonoscopy is not generally performed in the setting of KLA. (See "Pyogenic liver abscess", section on 'Association with colorectal neoplasia'.)
Most cases of K. pneumoniae primary liver abscess (KLA), particularly those associated with metastatic infection, have been reported in Taiwan and are community-acquired [1-12]. In a series of 248 patients with pyogenic liver abscess from Taiwan, for example, K. pneumoniae was responsible for 171 (69 percent) .
- Fang CT, Lai SY, Yi WC, et al. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis 2007; 45:284.
- Yu WL, Ko WC, Cheng KC, et al. Association between rmpA and magA genes and clinical syndromes caused by Klebsiella pneumoniae in Taiwan. Clin Infect Dis 2006; 42:1351.
- Wang JH, Liu YC, Lee SS, et al. Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clin Infect Dis 1998; 26:1434.
- Yang CC, Yen CH, Ho MW, Wang JH. Comparison of pyogenic liver abscess caused by non-Klebsiella pneumoniae and Klebsiella pneumoniae. J Microbiol Immunol Infect 2004; 37:176.
- Chan KS, Chen CM, Cheng KC, et al. Pyogenic liver abscess: a retrospective analysis of 107 patients during a 3-year period. Jpn J Infect Dis 2005; 58:366.
- Fung CP, Chang FY, Lee SC, et al. A global emerging disease of Klebsiella pneumoniae liver abscess: is serotype K1 an important factor for complicated endophthalmitis? Gut 2002; 50:420.
- Yeh KM, Kurup A, Siu LK, et al. Capsular serotype K1 or K2, rather than magA and rmpA, is a major virulence determinant for Klebsiella pneumoniae liver abscess in Singapore and Taiwan. J Clin Microbiol 2007; 45:466.
- Fang CT, Chuang YP, Shun CT, et al. A novel virulence gene in Klebsiella pneumoniae strains causing primary liver abscess and septic metastatic complications. J Exp Med 2004; 199:697.
- Chuang YP, Fang CT, Lai SY, et al. Genetic determinants of capsular serotype K1 of Klebsiella pneumoniae causing primary pyogenic liver abscess. J Infect Dis 2006; 193:645.
- Ko WC, Paterson DL, Sagnimeni AJ, et al. Community-acquired Klebsiella pneumoniae bacteremia: global differences in clinical patterns. Emerg Infect Dis 2002; 8:160.
- Tsay RW, Siu LK, Fung CP, Chang FY. Characteristics of bacteremia between community-acquired and nosocomial Klebsiella pneumoniae infection: risk factor for mortality and the impact of capsular serotypes as a herald for community-acquired infection. Arch Intern Med 2002; 162:1021.
- Cheng DL, Liu YC, Yen MY, et al. Septic metastatic lesions of pyogenic liver abscess. Their association with Klebsiella pneumoniae bacteremia in diabetic patients. Arch Intern Med 1991; 151:1557.
- Chung DR, Lee SS, Lee HR, et al. Emerging invasive liver abscess caused by K1 serotype Klebsiella pneumoniae in Korea. J Infect 2007; 54:578.
- Kang CI, Kim SH, Bang JW, et al. Community-acquired versus nosocomial Klebsiella pneumoniae bacteremia: clinical features, treatment outcomes, and clinical implication of antimicrobial resistance. J Korean Med Sci 2006; 21:816.
- Okano H, Shiraki K, Inoue H, et al. Clinicopathological analysis of liver abscess in Japan. Int J Mol Med 2002; 10:627.
- Siu LK, Fung CP, Chang FY, et al. Molecular typing and virulence analysis of serotype K1 Klebsiella pneumoniae strains isolated from liver abscess patients and stool samples from noninfectious subjects in Hong Kong, Singapore, and Taiwan. J Clin Microbiol 2011; 49:3761.
- Lee KH, Hui KP, Tan WC, Lim TK. Klebsiella bacteraemia: a report of 101 cases from National University Hospital, Singapore. J Hosp Infect 1994; 27:299.
- Nadasy KA, Domiati-Saad R, Tribble MA. Invasive Klebsiella pneumoniae syndrome in North America. Clin Infect Dis 2007; 45:e25.
- Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis 2004; 39:1654.
- Lederman ER, Crum NF. Pyogenic liver abscess with a focus on Klebsiella pneumoniae as a primary pathogen: an emerging disease with unique clinical characteristics. Am J Gastroenterol 2005; 100:322.
- Fang FC, Sandler N, Libby SJ. Liver abscess caused by magA+ Klebsiella pneumoniae in North America. J Clin Microbiol 2005; 43:991.
- Fierer J, Walls L, Chu P. Recurring Klebsiella pneumoniae pyogenic liver abscesses in a resident of San Diego, California, due to a K1 strain carrying the virulence plasmid. J Clin Microbiol 2011; 49:4371.
- McCabe R, Lambert L, Frazee B. Invasive Klebsiella pneumoniae infections, California, USA. Emerg Infect Dis 2010; 16:1490.
- Anstey JR, Fazio TN, Gordon DL, et al. Community-acquired Klebsiella pneumoniae liver abscesses - an "emerging disease" in Australia. Med J Aust 2010; 193:543.
- Yu VL, Hansen DS, Ko WC, et al. Virulence characteristics of Klebsiella and clinical manifestations of K. pneumoniae bloodstream infections. Emerg Infect Dis 2007; 13:986.
- Harris PJ, Laczek JT, Polish RD, Fraser SL. Two cases of Klebsiella pneumoniae primary liver abscesses; an emerging clinical entity among diabetics. Hawaii Med J 2005; 64:306.
- Braiteh F, Golden MP. Cryptogenic invasive Klebsiella pneumoniae liver abscess syndrome. Int J Infect Dis 2007; 11:16.
- Gomez C, Broseta A, Otero JR, et al. Primary pyogenic liver abscess cause by magA+ Klebsiella pneumoniae in Spain. Clin Microbiol Newsl 2007; 29:13.
- Karama EM, Willermain F, Janssens X, et al. Endogenous endophthalmitis complicating Klebsiella pneumoniae liver abscess in Europe: case report. Int Ophthalmol 2008; 28:111.
- Keynan Y, Karlowsky JA, Walus T, Rubinstein E. Pyogenic liver abscess caused by hypermucoviscous Klebsiella pneumoniae. Scand J Infect Dis 2007; 39:828.
- Hsu CR, Lin TL, Chen YC, et al. The role of Klebsiella pneumoniae rmpA in capsular polysaccharide synthesis and virulence revisited. Microbiology 2011; 157:3446.
- Vila A, Cassata A, Pagella H, et al. Appearance of Klebsiella pneumoniae liver abscess syndrome in Argentina: case report and review of molecular mechanisms of pathogenesis. Open Microbiol J 2011; 5:107.
- Sobirk SK, Struve C, Jacobsson SG. Primary Klebsiella pneumoniae Liver Abscess with Metastatic Spread to Lung and Eye, a North-European Case Report of an Emerging Syndrome. Open Microbiol J 2010; 4:5.
- Decré D, Verdet C, Emirian A, et al. Emerging severe and fatal infections due to Klebsiella pneumoniae in two university hospitals in France. J Clin Microbiol 2011; 49:3012.
- Merlet A, Cazanave C, Dutronc H, et al. Primary liver abscess due to CC23-K1 virulent clone of Klebsiella pneumoniae in France. Clin Microbiol Infect 2012; 18:E338.
- Moore R, O'Shea D, Geoghegan T, et al. Community-acquired Klebsiella pneumoniae liver abscess: an emerging infection in Ireland and Europe. Infection 2013; 41:681.
- Lee HC, Chuang YC, Yu WL, et al. Clinical implications of hypermucoviscosity phenotype in Klebsiella pneumoniae isolates: association with invasive syndrome in patients with community-acquired bacteraemia. J Intern Med 2006; 259:606.
- Yu WL, Fung CP, Ko WC, et al. Polymerase chain reaction analysis for detecting capsule serotypes K1 and K2 of Klebsiella pneumoniae causing abscesses of the liver and other sites. J Infect Dis 2007; 195:1235.
- Lin JC, Siu LK, Fung CP, et al. Impaired phagocytosis of capsular serotypes K1 or K2 Klebsiella pneumoniae in type 2 diabetes mellitus patients with poor glycemic control. J Clin Endocrinol Metab 2006; 91:3084.
- Yu WL, Chan KS, Ko WC, et al. Lower prevalence of diabetes mellitus in patients with Klebsiella pneumoniae primary liver abscess caused by isolates of K1/K2 than with non-K1/K2 capsular serotypes. Clin Infect Dis 2007; 45:1529.
- Li J, Fu Y, Wang JY, et al. Early diagnosis and therapeutic choice of Klebsiella pneumoniae liver abscess. Front Med China 2010; 4:308.
- Lin YT, Siu LK, Lin JC, et al. Seroepidemiology of Klebsiella pneumoniae colonizing the intestinal tract of healthy Chinese and overseas Chinese adults in Asian countries. BMC Microbiol 2012; 12:13.
- Lin YT, Liu CJ, Yeh YC, et al. Ampicillin and amoxicillin use and the risk of Klebsiella pneumoniae liver abscess in Taiwan. J Infect Dis 2013; 208:211.
- Sheu SJ, Kung YH, Wu TT, et al. Risk factors for endogenous endophthalmitis secondary to klebsiella pneumoniae liver abscess: 20-year experience in Southern Taiwan. Retina 2011; 31:2026.
- Ma LC, Fang CT, Lee CZ, et al. Genomic heterogeneity in Klebsiella pneumoniae strains is associated with primary pyogenic liver abscess and metastatic infection. J Infect Dis 2005; 192:117.
- Lee SS, Chen YS, Tsai HC, et al. Predictors of septic metastatic infection and mortality among patients with Klebsiella pneumoniae liver abscess. Clin Infect Dis 2008; 47:642.
- Chuang YC, Lee MF, Tan CK, et al. Can the rmpA gene predict metastatic meningitis among patients with primary Klebsiella pneumoniae liver abscess? J Infect 2013; 67:166.
- Chan KS, Yu WL, Tsai CL, et al. Pyogenic liver abscess caused by Klebsiella pneumoniae: analysis of the clinical characteristics and outcomes of 84 patients. Chin Med J (Engl) 2007; 120:136.
- Hui JY, Yang MK, Cho DH, et al. Pyogenic liver abscesses caused by Klebsiella pneumoniae: US appearance and aspiration findings. Radiology 2007; 242:769.
- Alsaif HS, Venkatesh SK, Chan DS, Archuleta S. CT appearance of pyogenic liver abscesses caused by Klebsiella pneumoniae. Radiology 2011; 260:129.
- Lee NK, Kim S, Lee JW, et al. CT differentiation of pyogenic liver abscesses caused by Klebsiella pneumoniae vs non-Klebsiella pneumoniae. Br J Radiol 2011; 84:518.
- Kawai T. Hypermucoviscosity: an extremely sticky phenotype of Klebsiella pneumoniae associated with emerging destructive tissue abscess syndrome. Clin Infect Dis 2006; 42:1359.
- Chou FF, Kou HK. Endogenous endophthalmitis associated with pyogenic hepatic abscess. J Am Coll Surg 1996; 182:33.
- Sheu SJ, Chou LC, Hong MC, et al. Risk factors for endogenous endophthalmitis secondary to Klebsiella pneumoniae liver abscess. Zhonghua Yi Xue Za Zhi (Taipei) 2002; 65:534.
- Keynan Y, Rubinstein E. Endogenous endophthalmitis caused by hypermucoviscous Klebsiella pneumoniae: an emerging disease in Southeast Asia and beyond. Curr Infect Dis Rep 2008; 10:343.
- Awaya H, Ito K, Honjo K, et al. Differential diagnosis of hepatic tumors with delayed enhancement at gadolinium-enhanced MRI: a pictorial essay. Clin Imaging 1998; 22:180.
- Chan JH, Tsui EY, Luk SH, et al. Diffusion-weighted MR imaging of the liver: distinguishing hepatic abscess from cystic or necrotic tumor. Abdom Imaging 2001; 26:161.
- Huang CI, Wang LY, Yeh ML, et al. Hepatocellular carcinoma associated with liver abscess. Kaohsiung J Med Sci 2009; 25:537.
- Chong VH, Lim KS. Pyogenic liver abscess as the first manifestation of hepatobiliary malignancy. Hepatobiliary Pancreat Dis Int 2009; 8:547.
- Lin TL, Tang SI, Fang CT, et al. Extended-spectrum beta-lactamase genes of Klebsiella pneumoniae strains in Taiwan: recharacterization of shv-27, shv-41, and tem-116. Microb Drug Resist 2006; 12:12.
- Li W, Sun G, Yu Y, et al. Increasing occurrence of antimicrobial-resistant hypervirulent (hypermucoviscous) Klebsiella pneumoniae isolates in China. Clin Infect Dis 2014; 58:225.
- Su SC, Siu LK, Ma L, et al. Community-acquired liver abscess caused by serotype K1 Klebsiella pneumoniae with CTX-M-15-type extended-spectrum beta-lactamase. Antimicrob Agents Chemother 2008; 52:804.
- Cheng HP, Siu LK, Chang FY. Extended-spectrum cephalosporin compared to cefazolin for treatment of Klebsiella pneumoniae-caused liver abscess. Antimicrob Agents Chemother 2003; 47:2088.
- Chen YJ, Kuo HK, Wu PC, et al. A 10-year comparison of endogenous endophthalmitis outcomes: an east Asian experience with Klebsiella pneumoniae infection. Retina 2004; 24:383.
- Tan YM, Chee SP, Soo KC, Chow P. Ocular manifestations and complications of pyogenic liver abscess. World J Surg 2004; 28:38.
- Yoon YH, Lee SU, Sohn JH, Lee SE. Result of early vitrectomy for endogenous Klebsiella pneumoniae endophthalmitis. Retina 2003; 23:366.
- Ang M, Jap A, Chee SP. Prognostic factors and outcomes in endogenous Klebsiella pneumoniae endophthalmitis. Am J Ophthalmol 2011; 151:338.
- Fang CT, Chen YC, Chang SC, et al. Klebsiella pneumoniae meningitis: timing of antimicrobial therapy and prognosis. QJM 2000; 93:45.
- Yu WL, Lee MF, Chen CC, et al. Impacts of Hypervirulence Determinants on Clinical Features and Outcomes of Bacteremia Caused by Extended-Spectrum β-Lactamase-Producing Klebsiella pneumoniae. Microb Drug Resist 2017; 23:376.
- PATHOGENESIS AND RISK FACTORS
- Host factors
- - Diabetes mellitus
- - Other host factors
- Virulence factors
- Antibiotic use
- Risk factors for metastatic disease
- CLINICAL MANIFESTATIONS
- Metastatic infection
- DIFFERENTIAL DIAGNOSIS
- Antibiotic choice
- Duration of therapy
- Treatment of metastatic infection