Septic Shock in Pyogenic Liver Abscess: Clinical Considerations

A Reum Cho; Tae Hee Lee; Min Ji Park; Sun Hee Oh; Joo Ah Lee; Joo Ho Park; Ki Hyun Ryu; Hoon Sup Koo; Kyung Ho Song; Sun Moon Kim; Kyu Chan Huh; Young Woo Choi; Young Woo Kang

doi:10.4166/kjg.2016.67.5.245

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Cho, Lee, Park, Oh, Lee, Park, Ryu, Koo, Song, Kim, Huh, Choi, and Kang: Septic Shock in Pyogenic Liver Abscess: Clinical Considerations

Original Article

Korean J Gastroenterol 2016;67(5):245-252.

Published online: 4 October 2016

DOI: https://doi.org/10.4166/kjg.2016.67.5.245

Septic Shock in Pyogenic Liver Abscess: Clinical Considerations

A Reum Cho, Tae Hee Lee, Min Ji Park, Sun Hee Oh, Joo Ah Lee, Joo Ho Park, Ki Hyun Ryu, Hoon Sup Koo, Kyung Ho Song, Sun Moon Kim, Kyu Chan Huh, Young Woo Choi, Young Woo Kang

Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea

Correspondence to: Tae Hee Lee, Department of Internal Medicine, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 35365, Korea. Tel: +82-42-600-9370, Fax: +82-42-600-9090, E-mail: green740@naver.com

Received 4 March 2016 Revised 29 April 2016 Accepted 1 May 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

Pyogenic liver abscess (PLA) is a life-threatening condition, despite advances in diagnostic technology and strategies for treatment. A strong predictor of mortality in this condition is septic shock. This study describes clinical, biochemical, and radiologic features in patients with PLA with or without septic shock, with the intent of describing risk factors for septic shock.

Methods

Of 358 patients with PLA enrolled, 30 suffered septic shock and the remaining 328 did not. We reviewed the medical records including etiologies, underlying diseases, laboratory, radiologic and microbiologic findings, methods of treatment and treatment outcomes.

Results

The case fatality rate was 6.1%. In univariate analysis, the presence of general weakness, mental change, low platelet level, prolonged PT, high BUN level, high creatinine level, low albumin level, high AST level, high CRP level, abscess size >6 cm, the presence of gas-forming abscess, APACHE II score ≥20, and the presence of Klebsiella pneumoniae infection were significantly associated with septic shock. Multivariate analysis showed the presence of mental change (p=0.004), gas-forming abscess (p=0.012), and K. pneumoniae infection (p=0.027) were independent predictors for septic shock.

Conclusions

The presence of mental change, gas-forming abscess, and K. pneumoniae infection were independent predictors for septic shock in patients with PLA.

Keywords: Pyogenic liver abscess, Septic shock, Mortality, APACHE II, Klebsiella pneumoniae

References

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Table 1.

Comparison of Baseline Characteristics between Patient Groups

Variable	All patients (n=358)	Non-septic shock (n=328)	Septic shock (n=30)	p-value
Gender (male)	216 (60.3)	199 (60.7)	17 (56.7)	0.668
Age (yr)	63.7±14.2	63.7±14.1	64.2±15.9	0.840
Alcoholism	120 (33.5)	110 (33.5)	10 (33.3)	0.982
Underlying disease
Diabetes mellitus	95 (26.5)	84 (25.6)	11 (36.7)	0.189
Hypertension	129 (36.0)	121 (36.9)	8 (26.7)	0.264
Liver cirrhosis	21 (5.9)	18 (5.5)	3 (10.0)	0.403
Chronic kidney disease	9 (2.5)	8 (2.4)	1 (3.3)	0.549
Malignancy	72 (20.1)	65 (19.8)	7 (23.3)	0.646
Origin of abscess
Cryptogenic	253 (70.7)	228 (69.5)	25 (83.3)	0.111
Biliary	82 (22.9)	78 (23.8)	4 (13.3)	0.258
Others ^a	23 (6.4)	22 (6.7)	1 (3.3)

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

^a Others: hepatocellular carcinoma, post transarterial chemoembolization, liver metastasis.

Table 2.

Comparison of Initial Symptoms and Signs between Patient Groups

Variable	All patients (n=358)	Non-septic shock (n=328)	Septic shock (n=30)	p-value
Fever/chill	290 (81.0)	264 (80.5)	26 (86.7)	0.626
Abdominal pain	170 (47.5)	159 (48.5)	11 (36.7)	0.215
General weakness	125 (34.9)	108 (32.9)	17 (56.7)	0.009
Poor oral intake	96 (26.8)	86 (26.2)	10 (33.3)	0.400
Nausea/vomiting	70 (19.6)	61 (18.6)	9 (30.0)	0.132
Mental change	15 (4.2)	6 (1.8)	9 (30.0)	<0.0001
RUQ tenderness	128 (35.8)	117 (35.7)	11 (36.7)	0.913
Murphy's sign	10 (2.8)	10 (3.0)	0 (0)	1.000
Jaundice	6 (1.7)	6 (1.8)	0 (0)	1.000
Ascites	7 (2.0)	5 (1.5)	2 (6.7)	0.110
Pleural effusion	30 (8.4)	28 (8.5)	2 (6.7)	1.000

Values are presented as n (%).

RUQ, right upper quadrant.

Table 3.

Comparison of Laboratory Findings, Radiologic Findings and APACHE II Score between the Patient Groups

Variable	All patients (n=358)	Non-septic shock (n=328)	Septic shock (n=30)	p-value
Laboratory findings
White blood cell (×10³/μ L)	10.7±5.2	13.0±6.1	11.0±7.1	0.104
Hemoglobin (g/dL)	12.3±1.7	11.9±1.9	11.7±2.0	0.548
Platelet (×10³/μ L)	120.2±106.8	195.3±157.2	85.2±65.6	<0.0001
PT (sec)	16.8±1.9	14.9±1.9	16.5±2.3	0.001
BUN (mg/dL)	39.7±24.7	19.0±11.7	34.6±21.6	0.001
Creatinine (mg/dL)	2.0±1.6	1.1±1.0	2.0±1.3	0.001
Albumin (g/dL)	3.1±0.3	3.3±0.6	3.0±0.6	0.027
ALP (IU/L)	211.4±220.2	184.3±122.9	184.5±157.3	0.994
AST (IU/L)	259.1±425.6	83.7±118.5	252.4±358.4	0.016
ALT (IU/L)	210.7±323.7	71.7±87.5	136.5±182.7	0.064
GGT (IU/L)	123.6±100.8	166.9±152.1	170.9±171.8	0.920
Bilirubin (mg/dL)	2.1±1.6	1.5±1.6	2.2±1.7	0.035
CRP (mg/dL)	22.6±7.8	16.5±9.2	24.3±7.8	<0.0001
Radiologic findings
Abscess size (cm)	5.4±2.8	5.2±2.9	6.7±2.0	0.007
Multiple abscesses	82 (22.9)	80 (24.4)	2 (6.7)	0.024
Bilobar involvement	29 (8.1)	28 (8.5)	1 (3.3)	0.492
Right lobar involvement	249 (69.6)	224 (68.3)	25 (83.3)	0.087
Gas-forming abscess	9 (2.5)	6 (1.8)	3 (10)	0.032
APACHE II score	7.5±4.5	7.0±4.1	13.0±5.7	<0.0001

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

APACHE, acute physiology and chronic health evaluation.

Table 4.

Microbiologic Spectrum in 358 Patients with Pyogenic Liver Abscess

Microorganism	Blood (n=125)	Abscess (n=170)
Klebsiella pneumoniae	94 (75.2)	128 (75.3)
Escherichia coli	17 (13.6)	19 (11.2)
Streptococcus sp.	5 (4.0)	6 (3.5)
Enterococcus sp.	3 (2.4)	7 (4.1)
Klebsiella oxytoca	3 (2.4)	5 (2.9)
Citrobacter sp.	3 (2.4)	4 (2.4)
Staphylococcus sp.	3 (2.4)	0
Pseudomonas aureginosa	1 (0.8)	4 (2.4)
Proteus sp.	1 (0.8)	2 (1.2)
Bacillus sp.	1 (0.8)	0
Enterobacter sp.	0	2 (1.2)

Values are presented as n (%).

Table 5.

Comparison of Microbiologic Characteristics between Patient Groups

Variable	All patients (n=358)	Non-septic shock (n=328)	Septic shock (n=30)	p-value
Bacteremia	125/342 (36.5)	103/312 (33.0)	22/30 (73.3)	<0.0001
Polymicrobial infection	16 (4.5)	13 (4.0)	3 (10.0)	0.141
Klebsiella pneumoniae infection ^a	175 (48.9)	152 (46.3)	23 (76.7)	0.001
ESBL (+)	4/175 (2.3)	3/152 (2.0)	1/23 (4.3)	0.434
Escherichia coli infection ^b	32 (8.9)	30 (9.1)	2 (6.7)	1.000
ESBL (+)	3/32 (9.4)	2/30 (6.7)	1/2 (50.0)	0.181

Values are presented as n (%).

ESBL, extended spectrum -lactamase.

^a K. pneumoniae was cultured from blood and/or abscess cultures.

^b E. coli was cultured from blood and/or abscess cultures.

Table 6.

Comparison of Treatment and Outcomes between Patient Groups

Variable	All patients (n=358)	Non-septic shock (n=328)	Septic shock (n=30)	p-value
Hospital stay (day)	27.8±145.5	28.5±152.0	19.2±13.1	0.737
ICU admission	67 (18.7)	40 (12.2)	27 (90.0)	<0.0001
Duration of intensive care unit	5.7±5.3	5.5±4.9	6.0±6.1	0.743
Treatment options
Antibiotics alone	119 (33.2)	113 (34.5)	6 (20.0)	0.108
Percutaneous drainage	237 (66.2)	213 (64.9)	24 (80.0)	0.095
Surgical drainage	7 (2.0)	6 (1.8)	1 (3.3)	0.461
Duration of intravenous antibiotics	18.5±9.8	18.4±9.8	18.8±11.0	0.855
Prognosis
Non-survivors	22 (6.1)	16 (4.9)	6 (20.0)	0.001

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

Table 7.

Logistic Regression Analysis for Septic Shock in Patients with Pyogenic Liver Abscess

Variable	Univariable		Multivariable
Variable	OR (95% CI)	p-value	OR (95% CI)	p-value
Initial symptoms
General weakness	2.66 (1.25–5.68)	0.009
Mental change	23.00 (7.48–70.73)	<0.0001	12.49 (2.21–70.65)	0.004
Laboratory findings
Platelet <130×10³/μL	5.85 (2.44–14.04)	<0.0001
PT >15 sec	4.27 (1.84–9.88)	<0.0001
BUN >20 mg/dL	7.28 (3.03–17.51)	<0.0001
Creatinine >1.2 mg/dL	8.58 (3.83–19.25)	<0.0001
Albumin <3 g/dL	2.89 (1.36–6.15)	0.004
AST >36 IU/L	13.85 (1.86–103.02)	<0.0001
ALT >38 IU/L	4.00 (1.37–11.74)	0.005
CRP >10 mg/dL	6.01 (2.48–14.54)	<0.0001
Radiologic findings
Abscess size >6 cm	2.43 (1.14–5.16)	0.018
Gas-forming abscess	5.96 (1.41–25.18)	0.032	14.01 (1.79–109.79)	0.012
APACHE II score ≥20	40.75 (7.80–212.85)	<0.0001
Klebsiella pneumoniae infection	3.81 (1.59–9.11)	0.001	4.42 (1.18–16.52)	0.027

APACHE, acute physiology and chronic health evaluation.

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