Predictors of Mortality in Korean Patients with Pyogenic Liver Abscess: A Single Center, Retrospective Study

Se Hoon Sohn; Kook Hyun Kim; Jae Hyun Park; Tae Nyeun Kim

doi:10.4166/kjg.2016.67.5.238

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Sohn, Kim, Park, and Kim: Predictors of Mortality in Korean Patients with Pyogenic Liver Abscess: A Single Center, Retrospective Study

Original Article

Korean J Gastroenterol 2016;67(5):238-244.

Published online: 4 October 2016

DOI: https://doi.org/10.4166/kjg.2016.67.5.238

Predictors of Mortality in Korean Patients with Pyogenic Liver Abscess: A Single Center, Retrospective Study

Se Hoon Sohn, Kook Hyun Kim, Jae Hyun Park, Tae Nyeun Kim

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea

Correspondence to: Kook Hyun Kim, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea. Tel: +82-53-620-3576, Fax: +82-53-654-8386, E-mail: Email: kimkh@yu.ac.kr

Received 26 March 2016 Revised 25 April 2016 Accepted 26 April 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

The mortality rate of pyogenic liver abscess (PLA) has decreased dramatically, but it remains a potentially life threatening disease. Most cases are cryptogenic or occur in elderly men with underlying biliary tract disease. Although several studies have addressed the characteristics and etiology of PLA, research on factors affecting PLA-associated mortality is lacking. This study intended to identify the clinical and radiological features, pathogens, complications, and predictors of mortality in Korean PLA patients.

Methods

The medical records of 231 PLA patients diagnosed at Yeungnam University Medical Center between January 2010 and January 2014 were analyzed. A diagnosis of PLA was made based on imaging studies and blood and abscess cultures. The clinical, radiological, and laboratory findings of patients were analyzed.

Results

The mean patient age was 64.0±12.9 years and the male to female ratio was 1.5:1. Klebsiella pneumoniae was the predominant organism isolated from hepatic abscesses (69.9%) and blood (74.2%). The most common complication was pleural effusion (35.8%) and most common coinfection was cholangitis (8.2%). The overall mortality rate of PLA was 6.9% (16/231), and was significantly higher in patients with a history of liver abscess (OR 5.970, 95% CI 1.207–29.529; p=0.028), bilirubinemia (>2 mg/dL) (OR 9.541, 95% CI 2.382–38.216; p=0.001), thrombocytopenia (<140×10³/μ L) (OR 4.396, 95% CI 1.130–17.106; p=0.033), or anemia (<12 g/dL) (OR 13.277, 95% CI 1.476–119.423; p=0.021).

Conclusions

The prognosis of PLA appears to be dependent on underlying pathologies and severity of condition. More aggressive treatment should be considered if a poor prognosis is expected.

Keywords: Pyogenic liver abscess, Risk factors, Klebsiella pneumoniae

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Table 1.

Patient Baseline Characteristics

Variable	Patient (n=231)
Gender (male/female)	139/92 (60.2/39.8)
Age (yr)	64.0±12.9 (27–94)
Diabetes	53 (22.9)
Chronic hepatitis B/chronic hepatitis C	14/3 (6.1/1.3)
Liver cirrhosis	13 (5.6)
Heavy alcohol use	50 (21.6)
Stone	87 (37.7)
Gallbladder/CBD/IHD	55/14/18
	(23.8/6.1/7.8)
Gallbladder polyp	5 (2.2)
Malignancy	34 (14.7)
Common bile duct cancer	9 (3.9)
Gallbladder cancer	6 (2.6)
Cholangiocarcinoma	2 (0.9)
Hepatocellular carcinoma	4 (1.7)
Pancreatic cancer	1 (0.4)
Ampulla of Vater cancer	2 (0.9)
Chemotherapy or radiation history	11 (4.8)
Previous biliary surgery	46 (19.9)
Cryptogenic	95 (41.1)
Radiological characteristics
Location
Right/left/both	136/72/23
	(58.9/31.2/10.0)
Size (cm)	5.33±2.73 (1–16)
Number
Solitary/multiple	188/40 (81.4/17.3)
Multi-septated	116 (50.2)
Gas forming	20 (8.7)

Values are presented as n (%) or mean±SD (range).

CBD, common bile duct; IHD, intrahepatic duct.

Table 2.

Microorganisms Isolated by Site

Microorganism	Total (n=124)	Blood (n=31)	Abscess (n=93)	Both (n=26)
Klebsiella pneumoniae	88 (71.0)	23 (74.2)	65 (69.9)	19 (73.1)
Escherichia coli	13 (10.5)	3 (9.7)	10 (10.8)	3 (11.5)
Enterococcus spp.	4 (3.2)	1 (3.2)	3 (3.2)	1 (3.8)
Streptococci spp.	4 (3.2)	2 (6.5)	2 (2.2)	2 (7.7)
Pseudomonas spp.	3 (2.4)	1 (3.2)	2 (2.2)	1 (3.8)
Staphylococci spp.	1 (0.8)	0	1 (1.1)	0
Etc. ^a	11 (8.9)	1 (3.2)	10 (10.8)	0

Values are presented as n (%).

^a Include 2 Acinetobacter baumannii, 2 Enterobacter cloacae, 2 Aeromonas hydrophila, 1 Citrobacter braakii, 1 Citrobacter freundii, 1 Actinomycosis, 1 Salmonella typhi, 1 Klebsiella oxytoca.

Table 3.

Co-infections and Complications of Pyogenic Liver Abscess

Variable	Patient (n=231)
Co-infections
Cholangitis	19 (8.2)
Intraabdominal abscess	17 (7.4)
Cholecystitis	16 (6.9)
Pneumonia	13 (5.6)
Urinary tract infection	6 (2.6)
Endophthalmitis	4 (1.7)
Others ^a	4 (1.7)
Complications
Pleural effusion	83 (35.9)
Acute renal failure	2 (0.9)
Portal vein thrombosis	2 (0.9)
Gastrointestinal bleeding	1 (0.4)

Values are presented as n (%).

^a Include 1 empyema, 1 osteomyelitis, 1 infective endocarditis, 1 pyogenic arthritis.

Table 4.

Causes of Death in Patients with Pyogenic Liver Abscess

Variable	Patient (n=16)
Sepsis	11 (68.8)
Cancer progression	2 (12.5)
Empyema	2 (12.5)
Asphyxia	1 (6.3)

Values are presented as n (%).

Table 5.

Significant Mortality Risk Factors

Variable	Univariate		Multivariate
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
Liver cirrhosis	7.630 (2.051–28.383)	0.008
Cancer history	5.719 (2.002–16.334)	0.002
Biliary operation history	4.658 (1.645–13.188)	0.005
Recurrence	3.882 (1.129–13.352)	0.045	5.970 (1.207–29.529)	0.028
Pleural effusion	6.085 (1.895–19.540)	0.001
Hypoalbuminemia (<3.5 g/dL)	1.778 (1.58–2)	0.001
Bilirubinemia (>2 mg/dL)	7.574 (2.351–24.397)	0.001	9.541 (2.382–38.216)	0.001
Thrombocytopenia (<140×10³/μ L)	5.952 (1.855–19.23)	0.001	4.396 (1.130–17.106)	0.033
Anemia (<12 g/dL)	25 (3.28–200)	0.001	13.277 (1.476–119.423)	0.021
Gas forming abscess	8.614 (2.733–27.151)	0.001
Diabetes	1.166 (0.346–3.659)	0.776

Table 6.

Baseline Characteristics, Comorbidities and Treatment Outcomes of Klebsiella pneumoniae and Escherichia coli Pyogenic Liver Abscess

	K. pneumonia (n=91)	E. coli (n=13)	p-value
Male	52 (57.1)	7 (53.8)	0.822
Age (yr)	64.29±12.21	72.00±10.44	0.033
Comorbidity
Diabetes	24 (26.4)	3 (23.1)	1.000
CRF	2 (2.2)	0 (0.0)	1.000
Heavy alcohol use	19 (20.9)	1 (7.7)	0.454
GB stone	22 (24.2)	3 (23.1)	1.000
Biliary stone	12 (13.2)	4 (30.8)	0.113
Biliary operation	13 (14.3)	8 (61.5)	0.001
ERCP History	15 (16.5)	7 (53.8)	0.006
Cancer related abscess	11 (12.1)	5 (38.5)	0.028
Positive of ESBLs	8 (8.8)	4 (30.8)	0.042
Image study
Abscess size (cm)	5.73±2.56	5.14±3.00	0.448
Gas forming abscess	10 (11.0)	2 (15.4)	0.644
Solitary abscess	74 (81.3)	8 (61.5)	0.241
Abscess location			0.137
Right	60 (65.9)	5 (38.5)
Left	22 (24.2)	5 (38.5)
Both or junction	9 (9.9)	3 (23.1)
Treatment outcomes
Median length of hospital stay (day)	19.02±15.03	14.76±10.45	0.327
PCD insertion	74 (81.3)	10 (76.9)	0.712
Operation	0 (0)	1 (7.7)	0.125
Mortality	5 (5.5)	3 (23.1)	0.060

Values are presented as n (%) or mean±SD.

CRF, chronic renal failure; GB, gallbladder; ESBLs, extended-spectrum beta-lactamases; PCD, percutaneous abscess drainage.

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