an increasing prominent disease of klebsiella pneumoniae liver

Hindawi Publishing CorporationGastroenterology Research and PracticeVolume 2013 Article ID 258514 12 pageshttpdxdoiorg1011552013258514

Review ArticleAn Increasing Prominent Disease of Klebsiella pneumoniaeLiver Abscess Etiology Diagnosis and Treatment

Yun Liu Ji-yao Wang and Wei Jiang

Department of Gastroenterology Zhongshan Hospital Fudan University Xuhui Shanghai 200032 China

Correspondence should be addressed to Wei Jiang jiangweizs-hospitalshcn

Received 3 May 2013 Accepted 15 July 2013

Academic Editor Edoardo Giovanni Giannini

Copyright copy 2013 Yun Liu et al This is an open access article distributed under the Creative Commons Attribution License whichpermits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background During the past two decades Klebsiella pneumoniae (K pneumoniae) had surpassed Escherichia coli (E coli) as thepredominant isolate frompatients with pyogenic liver abscess (PLA) inAsian countries theUnited States and Europe and it tendedto spread globally Since the clinical symptom is atypical the accurate and effective diagnosis and treatment of K pneumoniae liverabscesses (KLAs) are very necessaryMethods Here we have comprehensively clarified the epidemiology and pathogenesis of KLAput emphases on the clinical presentations especially the characteristic radiographic findings of KLA and thoroughly elucidatedthe most effective antibiotic strategy of KLA Results K1 serotype is strongly associated with KLA especially in diabetic patientsComputed tomography (CT) and ultrasound (US) were two main diagnostic methods of KLA in the past Most of KLAs havesolitary septal lobular abscesses in the right lobe of liver and they aremainlymonomicrobial Broad-spectrum antibiotics combinedwith the US-guided percutaneous drainage of liver abscesses can increase their survival rates but surgical intervention still hasits irreplaceable position Conclusion The imaging features contribute to the early diagnosis and the percutaneous interventioncombined with an aminoglycoside plus either an extended-spectrum betalactam or a second- or third-generation cephalosporin isa timely and effective treatment of KLA

1 Introduction

Pyogenic liver abscess (PLA) is a life-threatening infectiousdisease Before the 1980s E coli was the most commonpathogen that caused PLA and was mostly polymicrobialHowever during the past two decades highly virulent strainsof K pneumoniae had emerged as a predominant cause ofPLA in Asian countries and areas [1ndash5] the United States[6ndash11] and Europe [12ndash14] especially Taiwan [2 15ndash22] andit tended to spread globally [23ndash26] Recent researches haveshown unlike other bacterial-induced PLAs (Non-KLAs)which are mostly associated with biliary tract disorders [1927ndash30] that K pneumoniae liver abscesses (KLAs) are oftencryptogenic [3 6 17 27 29ndash34] Metastatic meningitis orendophthalmitis is often complicated with KLA 10ndash45 [916 30 35ndash38] andmost of KLApatients had diabetesmellitus[1 15 16 22 27 29 30 35 38 39] KLA has the characteristicradiographic findings which are different from those of Non-KLA [1 6 22 30 34 38 40 41]Up to date the combination ofsystemic antibiotics and percutaneous drainage has become

the treatment of choice for the management of KLA [9 15 1638 42 43]

In this paper we comprehensively described the epi-demiology and the pathogenesis of KLA And then we putemphases on the difference of clinical presentations especiallythe radiographic findings between KLA and other kinds ofPLA (Non-KLA) in order to diagnose KLA early and pre-cisely and further elucidate the effective therapeuticmethodsof KLA especially the choice of targeted antibiotics We hopeto enhance the understanding of KLA and contribute to thetimely accurate and effective diagnosis and treatment of thisdisease

2 Epidemiology

In the recent two decades K pneumoniae has become themost common causative pathogen of PLA in Asian countriesand areas [1ndash5 15ndash22] A shift from E coli to K pneumoniaeas the causative pathogen of pyogenic liver abscess may also

2 Gastroenterology Research and Practice

have occurred in the United States [6ndash11] and Europe [12ndash14] However differing from the much higher incidence ofKLA in Asian countries and areas [1ndash5] especially the highestincidence in Taiwan that ranges from 80 to 90 [16 19]a relatively low incidence of 30ndash40 is estimated in theUS [6 9] The exact cause for the increasing prevalence ofKLA in Asia is not known but it may be related to the largepopulation of Asia the host susceptibility to infection thedifference in carriage rates and the environmental factorsor the emergence of a distinct strain of K pneumonia andan increased propensity to cause liver abscesses might bepotentially contributing to such a geographical difference inthe epidemiology of K pneumonia infection For exampleChung et al had noted that people of Korean ethnicitywho had lived in countries other than Korea had a lowerproportion of carrying serotype K1 of K pneumonia strainsthan those who lived in Korea [3] These findings indicate apotential role of the environmental factors in the intestinalcolonization of these strains

The middle-to-older-aged patients are at higher risk ofdeveloping KLA The peak incidence of the disease is 55ndash60 years old [4 6 7 9 16 19 40 41] Reports of KLA inchildren are rare [44] Male dominance is found in patientswith KLA and the male-to-female ratio is approximately 15ndash25 1 [4 7 9 14 16 19 21 35 36 38 41] (Table 1)

The mortality rate of KLA is lower than that of the Non-KLA [16 19 35] ranging from 2 to 18 [6 7 15 16 1819 35 36 38 40 46ndash48] Owing to the improvement ofdiagnosis and peoplersquos awareness of treatment the mortalityrate decreases

3 Etiology

KLAs are usually primary and cryptogenic [3 6 17 27 29ndash34] and cryptogenic invasive KLAs are frequently associatedwith diabetes mellitus [22] but they does not show anyclear association with peritoneal sources of infections suchas hepatobiliary obstruction pancreatitis enterocolitis ormalignant diseases

Some studies manifested that translocation from thegastrointestinal tract maybe the most likely route by whichK pneumonia caused liver abscess [3 20] Fung et al demon-strated that gastrointestinal carriage was a predisposingfactor for liver abscess [20] Furthermore they also foundthat patients with KLA and healthy carriers had identicalpulsed-field gel electrophoresis (PFGE) profileswith the samevirulence-associated genes and similar LD50 values In arecent investigation Lin et al reported a fecal carriage rate ofK pneumonia in healthy adults of 75 and high prevalence(23) of serotype K1K2 isolates among typical strains inTaiwan [49] K pneumonia can colonize the gastrointestinaltract of humans which suggests that colonization by theK pneumoniae strains precedes invasion of the intestinalmucosa and portal venous flowor ascending biliary infectionwhich is followed by the development of liver abscess

Several studies have found that capsule K1 and K2 werethe most two common causes of KLA (Table 2) K1 isolatesoccur at a significantly higher frequency than those of all

other serotypes especially in patients with diabetes mellitus[15] A recent case-control study performed by Kim et alsuggested that diabetes mellitus was an important underlyingfactor that correlates with a high incidence of K1 serotype inKLA [29] Poor glycemic control plays an important role inimpairing the neutrophil phagocytic function of patients withK1K2-typeKLAwhereas it does not significantly affect thoseof patients with non-K1K2 KLA [50] Capsule k1 serotypeis found to express the hypermucoviscous phenotypes whichcan produce vast amounts of extracapsular polysaccharideconstituting a mucoviscous web that protects these strainsfrom phagocytosis by neutrophils and from serum killing bycomplement [2 13 51] In addition in vitro serumassays showa significantly higher serum resistance on average for K1 thanK2 strains indicating that K1 and K2 strains have unequalvirulence [18] Recently most isolates of serotype K1 fromKLA patients belong to ST23 which is the most prevalentsequence type among serotype K1 isolates [2 24 26]

4 Bacterial Genes and Pathogenesis

A number of bacterial genes which are significantly corre-lated with the high virulence of the invasive strains [2 24 2652] have been proposed or suggested to play key roles in thepathogenesis of hepatovirulent KLA (Table 2)

The rmpA gene (a regulator of the mucoid phenotype)which is a transcriptional activator of the cps genes and func-tions as a positive regulator of extracapsular polysaccharidesynthesis has a strong association with hypermucoid strainsin PLA [18 52 53] Loss of this regulator will downregulatecapsule synthesis and knockout of the rmpA gene candecrease virulence in mouse lethality tests by 1000 folds [12]leading to the loss of phagocytic resistance and the mucoidphenotype Hsu et al found a correlation of rmpAA2with sixPLA-related capsular types (K1 K2 K5 K54 K57 and KN1)However the correlation of rmpAA2with K1 strains from theWest was less obvious than with the strains from Asia [53]

On the other hand magA a chromosomal gene whichis located in the cps (capsular polysaccharide synthesis)operon has been recently renamed wzyKpK1 and has beenshown to be specific for K1 capsule formation [26] MagAcan contribute to capsular polysaccharide formation and itis identified as an important virulence gene in invasive Kpneumoniae strains causing primary liver abscess and septicmetastatic complications [54] MagAmutants are also shownto lose the potential to produce this protective mucus andbecame susceptible to human serum and phagocytosis

The growth of bacteria in host tissues is limited notonly by host defense mechanisms but also by their supply ofavailable ironMany bacteria attempt to secure their supply ofiron in the host by secreting high-affinity iron chelators calledsiderophores like aerobactin Aerobactin an iron chelatorcalled iron siderophore can increase virulence in mouselethality tests by 100 folds [55]

A 20 kb chromosomal region including an iron uptakesystem (kfu) and a phosphoenolpyruvate sugar phospho-transferase system (PTS) was found to be presented in mostof the genomes of the tissue-invasive K pneumoniae strains

Gastroenterology Research and Practice 3Ta

ble1Dem

ograph

icclin

icalcharacteris

ticsa

ndtre

atmento

fpatientsw

ithKlebsiella

pneumoniaeliver

abscessesfrom

case

repo

rts

Case

Age

Sex

Race

Und

erlyingdiseases

Symptom

Locatio

nof

medicaltherapy

Outcome

Reference

164

FFilip

ino

Diabetesm

ellitus

thrombo

cytosis

Feverrig

orsnausea

andmyalgias

Rightlob

e

Piperacilin

-tazobactam

(337

gQ6h

)+gentam

icin

(400

mgq

d)ceft

riaxone

(2givqd

)+oralmetronidazole(500

mgivfour

times

daily)

follo

wed

bylevoflo

xacinandmetronidazolefor4

wks

Survived

[7]

271

MCa

ucasian

Coron

aryartery

disease

Feverabdo

minal

painand

hypo

tension

Leftlobe

Cefotetan

(2gBID)+

orallevoflo

xacin(500

mgqd

)for8

wks

Survived

[7]

353

MCa

ucasian

Mitralvalvep

rolapse

and

hypercho

leste

rolemia

Feverrig

orsfatig

ue

malaisenight

sweats

andtooth

pain

Leftlobe

Ceft

riaxone

+metronidazolefor4

wksgentamicin

for2

wksfollowe

dby

oralciprofl

oxacin

for1

mon

thSurvived

[7]

464

FFilip

ino

Pepticulcerd

isease

coronary

artery

diseaseand

hypertensio

n

Feverrig

htabdo

minalpainand

anorexia

Leftlobe

Ciprofl

oxacin

(400

mgiv

bid)

+metronidazole

(500

mgiv

tid)follo

wedby

oralciprofl

oxacin

+metronidazolefor6

wks

Survived

[7]

556

MFilip

ino

Non

eFeverchillsnight

sweats

epigastric

painand

nausea

Rightlob

e

Piperacillintazobactam

(q6h

)+metronidazole

(500

mgq8h)gentamicin

(180

mgq18h

)follo

wed

byorallevoflo

xacin(500

mgqd

)+metronidazole

(500

mgtid

)for

6wks

Survived

[7]

659

FFilip

ino

Diabetesm

ellitus

Feverchills

anorexiaand

fatig

ueLeftlobe


(337

5gq6h

)+metronidazole(500

mgq8h)ceft

riaxone

(2gday)

+metronidazole(500

mgq8h)

for4

wksfollowed

byorallevoflo

xacin(500

mgday)

for3

mon

ths

Survived

[7]

755

MArgentin

ian

Non

eFevera

ndfatig

ueNR

Ceft

riaxone

+metronidazole

follo

wed

byoral

ciprofl

oxacin

for6

wkspercutaneou

sdrainage

Survived

[26]

847

FOmani

Non

e

Feverchillsrig

ors

mild

coug

hpo

ororalintakeand

inabilityto

walk

Rightlob

eAu

gmentin

(2givq6

h)+gentam

icin

(17gIV

q8h)

for3

wkscatheterd

rainage

Survived

[18]

958

FOmani

Diabetesm

illitu

sFevermalaiseand

nausea

Rightlob

e

Amikacin

(1gIV

q12h)+

cefta

zidime(15

gIV

q8h

for5

days)follo

wed

byciprofl

oxacin

(05gIV

q12h

for12d

ays)andpiperacillintazobactam

(45giv

q8h)

for15d

ays

Survived

[18]

1062

MIrish

Perip

heralvascular

diseasea

ndexcess

alcoho

lintake

Abdo

minalpain

anorexiaandnausea

NR


(45givq8h)

for15d

ays

Survived

[14]

1140

MFilip

ino

Diabetesm

ellitus

Feverpo

lydipsia

andpo

lyuria

Rightlob

eCeft

riaxone

(2givqd

)oralciprofl

oxacin

for6

9days

percutaneous

drainageintraveno

usgentam

icinand

ciprofl

oxacin

(400

mgivbid)

for5

days

Survived

[14]

1255

MCh

inese

Diabetesm

ellitus

Vomiting

abdo

minalpain

feverandrig

ors

Rightlob

e

Oralciproflo

xacinfor3

6daysoralceph

alexin

for

97daysamoxicillin-clavulanica

cid(12giv

tid)+

gentam

icin

(320

mgday)

+metronidazole(500

mg

ivtid

)follo

wed

byceftriaxone

(2gdaysdotiv)+

oral

metronidazole(400

mgbid)percutaneou

sdrainage

Survived

[14]


Table1Con

tinued

Case

Age

Sex

Race

Und

erlyingdiseases

Symptom

Locatio

nof

medicaltherapy

Outcome

Reference

1358

MJapanese

Diabetesm

ellitus

Malaise

Rightlob

eMerop

enem

(1givq12h)for

6dayscefm

etazole(

2givQ8h

)oralcefcapenep

ivoxil(100

mgtid

)and

antib

iotic

treatmentfor

30days

Survived

[5]

1461

FJapanese

Diabetesm

ellitus

Feverchillsanda

slighth

eadache

NR

Merop

enem

(1giv

q8h)

+lin

ezolid

(600

mgiv

q12h

)changedto

ceftriaxone

(2gq12h

)for

20days

follo

wed

byoralceph

alexin

(250

mgq6

h)for3

1days

Survived

[5]

1543

MJapanese

Non

eRight

hypo

chon

driaca

ndepigastricpain

Rightlob

eMerop

enem

(1gd

ayiv)for

15days

+IV

insulin

mgdayandoralciprofl

oxacin

(400

mgday)

for

50days

Survived

[45]

NR

notreported

Gastroenterology Research and Practice 5

Table 2 Genes associated with the serotypes of K pneumonia

Gene Comment K1 K2 Non-K1K2 ReferenceMagA Capsular polysaccharide synthesis + sect sect [24 26]RmpA Regulator of the mucoid phenotype + + + [2 26 52]kfuPTS Iron uptake system (kfu) and a phosphoenolpyruvate + minus + [52]Aerobactin An iron chelator + + + [2 26 52]AllS Anaerobic metabolism of allantoin + minus minus [52]No of isolates ()(119899 = 248) mdash 6340 1420 2240 [15]

sect No data minus lack of this gene

[18 56] Iron uptake is critical to pathogenesis as a vitalcofactor for many components of microbial antioxidativestress defense The kfuPTS region could enrich the ability ofbacteria to secure iron even in the relatively iron-deficientconditions of the human host and to eventually enhancethe virulence of the bacteria The celB gene which encodesthe putative cellobiose-specific PTS has been confirmed toplay an important role in the virulence of PLA-associated Kpneumonia strains When deleting the celB the PTS activityis significantly decreased the biofilm development is delayedand the thickness of the biofilmdoes not further increase [57]

The allS gene that possessed a 22 kb region associatedwith anaerobic metabolism of allantoin as the sole sourceof carbon nitrogen and energy under either aerobic oranaerobic condition [58] is only found in K1 isolates [52](Table 2) The allS region can help bacteria to compete fornitrogen sources via the allantoin-utilizing ability

5 Clinical Manifestations

The presentations of KLA are not typical and patients maypresent with vague constitutional symptoms The relativelycommon presentation features are fever [7 9 13 16 26 2835 38 41] and chills [7 28 35 38 41] followed by rightabdominal pain [7 16 38] Fever is predominant as themost common symptom and has been reported in 90ndash95of the cases [9 16 38] (Table 1) But there is also a broadarray of nonspecific symptoms like diarrhea jaundice rightpleural effusion [38] anorexia nausea and vomiting [9 16]Although the case of spontaneous rupture of a liver abscesshas been rarely reported there is a higher incidence of abscessrupture in theKLApatients than inNon-KLApatients [16 2734 38] The risk factors for spontaneous rupture in KLA arediabetes mellitus large abscess size thined-wall abscess andgas-forming abscess [34 38 59]

KLA is also associated with a higher likelihood of hem-atogenous spread and the potential for metastatic infectionin other parts of the body compared with other kinds of PLA[16 21 27 30 35 38 40 41 50 56] The high incidence rateof metastatic infection ranges from 10 to 45 [9 16 30 35ndash38] especially in patients with diabetesmellitus [14 15 22 3035 38 39 50] Patients with diabetes mellitus are at increasedrisk for common infection due to impaired host-defensemechanisms Furthermore abscess with size of 5-6 cm isproven to be a significant independent predictor of KLA

patients withmetastatic infections [22 39] It is suggested thatwe should not neglect the small-sized liver abscess in diabeticpatients in the early course of the disease for hematogenousdissemination of K pneumonia can occur which leads thesevere clinical symptoms that can result in earlier detectionof liver abscess and this supported the metastatic infectionsof small-sized KLA

Eyes [9 11 13 15 30 35 36 38] meninges [16 35] CNS[16 30] and lungs [9 13 16 30] are the most commonmetastatic sites Endophthalmitis is the most common andserious septic complication of KLA leading to subacutevision impairment These patients usually do not recovertheir vision and become legally blind despite aggressiveintravenous and intravitreous antibiotics [13 15 35] Recentlytwo studies indicated that the mortality rate of KLA patientswith metastatic infections was significantly higher than thatwithout metastatic infections (16-17 versus 0ndash11) [2239]

In terms of underlying diseases individuals with KLAhave a lower proportion of comorbidity such as malignancy[38] liver cirrhosis chronic kidney disease and biliarydisease [30] than did Non-KLA ones a significantly higherproportion of DMon the other hand [29 33] Other presenta-tions such as bacteremia septic shock disseminated intravas-cular coagulation acute renal failure and acute respiratoryfailure are also reported to be more prevalent in KLA than inNon-KLA patients [38]

Onphysical presentations fever and right upper quadranttenderness are the most common findings Jaundice is foundin the patients with underlying biliary disease Hepatomegalyis less common in KLA than in Non-KLA patients [38]

6 Laboratory and Imaging Findings

Anemia leukocytosis high erythrocyte sedimentation rateC-reactive protein hypoalbuminemia elevated total biliru-bin and alanine aminotransferase are the common featuresA recent study in the USA found an elevated white blood cellcount in 68 a low albumin level in 702 and an elevatedalkaline phosphatase level in 67 of PLA [6] None of theblood tests specifically helps to diagnose a liver abscess butthey can suggest a liver abnormality that leads to imagingstudies

The most essential technology to make the diagnosis ofKLA is radiographic imaging Pulmonary X-ray can reveal


right-sided pulmonary infiltrates with pleural effusion [3460] and plain abdominal X-rays which are rarely used butcan be helpful in some cases can show air-fluid levels [45 59]or portal venous gas And now US and CT are two maindiagnostic methods which are both sensitive in the diagnosisof KLA

The appearance of KLA at US imaging may range fromhyperechoic to hypoechoic and this variation has a closerelationship to the pathologic stage of KLA Hui et al foundthat 84 patients predominantly had a solid appearanceunlike other PLAs in US imaging and that 52 patients haddiabetes mellitus [40] However Lee et al found that KLApredominantly had a solid appearance but did not showmuchassociation with diabetes mellitus (the prevalence of diabetesmellitus between KLA and Non-KLA is 610 versus 514resp) [30] Overall KLA appears as hypoechoic nodules andsolid in US appearance imaging

The sensitivity of CT was reported to reach as high as100 comparedwith a sensitivity of 96 of US [47] Recentlyvarious studies were reported to compare the differences ofCT imaging between KLA and Non-KLA [1 27 30 38 41](Table 3) Most of KLA patients have a solitary abscess in theright lobe of liver due to its size and propensity to receivemostof the portal blood flow [1 6 9 27 28 30 35 38 40 41]which does not show much difference from Non-KLA ones[1 27 30 38] However some reports found that KLAs weremore likely to appear as single abscesses [35 41] and unilobarinvolvements [41] than Non-KLAs (unilobar 826 versus615) The majority of liver abscesses in the two groups arenot more than 10 cm in diameter and there are no significantdifferences between KLA and Non-KLA with respect to thesize of the abscess cavity [1 35 38 41] KLA is predominantlywith septations in the abscess (ie multilocular) which issimilar to that of Non-KLA [30 38 41] whereas multilocularabscesses are more common in the KLA group than in theNon-KLA group [41] Gas-forming liver abscess had beenrarely reported in pyogenic liver abscess in the past howeverwith the etiologic shift to K pneumoniae as the primarycausative agent of PLA infections there is an increased riskof gas-producing liver abscess especially in patients withuncontrolled DM [1 5 22 45 60] In our previous researchwe found that KLA was more associated with gas-formationthan Non-KLA [24(329) versus 5 (135)] [1] (Figure 1) Itis assumed that under anaerobic conditions these facultativeanaerobes can produce carbon dioxide by fermentation ofglucose in tissue especially under hyperglycemic conditionsNo differences are found between groups regarding thepresence of gas bubbles [30 35 38 41] as shown in Table 3however KLA also shows a trend toward higher incidenceof thrombophlebitis whereas pneumobilia is more commonin the Non-KLA group [41] Other series do not show muchdifference between KLA and Non-KLA on account of theincidence of pneumobilia and thrombophlebitis [1 38]

On CT imaging liver abscesses are of lower attenuationthan the surrounding normal liver parenchyma thin-walledabscess on unenhanced scans [30 34 38] The abscess wallusually shows a rim-enhancement on contrast-enhanced CT[38]

7 Therapy

71 Antibiotics Medication When the diagnosis of KLA issuspected broad-spectrum antibiotics are started imme-diately to control ongoing bacteremia and its associatedcomplications Many studies have found that most isolatesare resistant to ampicillin [7 9 15ndash17 26 29 51] withan MIC90 of 32mgmL [17] and penicillin [9 29] butsusceptible to third- and fourth-generation cephalosporinsquinolones aminoglycosides and carbapenems [4 15ndash17 3861] Cephalosporins have a dominant position in antibiotictreatment of KLA [4 38 62] (Table 4)

Although a significantly higher complication rate is foundin KLA patients treated with cefazolin than in those treatedwith an extended-spectrum cephalosporin [63] anotherresearch has shown the similar therapeutic effects betweenpatients treated with extended-spectrum cephalosporinsand those treated with a combination of first-generationcephalosporins and aminoglycosides furthermore the lattertreatment is recommended for patients without risk factorssuch as endophthalmitis and meningitis [62] (Table 4)

The third-generation cephalosporin is used more inpatients with KLA group as compared with that in theStreptococcus milleri (SM) group [38]The SM group tends touse extended-spectrumpenicillinmore whereas 10ofKleb-siella isolates are resistant to penicillin Initial antibiotic reg-imens should comprise a second-generation cephalosporinand an aminoglycoside with metronidazole when treatingPLA caused by E coli isolates whereas the first-generationcephalosporin covers most pathogens found in KLA [27]

The optimal duration intravenous therapy as well as theduration of subsequent oral therapy remains unclear In thestudy of Taiwan therapy generally consisted of 3 weeks ofintravenous antibiotics followed by 1-2months of oral therapy[16] However aUS study in 2004 indicated shorter courses ofantibiotic therapy with durations of intravenous therapy (175days) and oral therapy (136 days) whichwere associatedwithextremely low mortality [6]

The treatment of KLA without metastatic infectionsincludes pigtail catheter drainage by negative-pressure andcombination of parenteral cefazolin and gentamicin for twoweeks [16] Gentamicin is discontinued after 2 weeks toavoid nephrotoxicity but cefazolin is continued for at least3 weeks and oral cephalosporin for 1-2 months to preventrelapse In patientswith septic endophthalmitis or other distalmetastases the prognosis is bad Systemic intravenous andintravitreous antibiotics are necessary [35 64 65] For exam-ple a third-generation cephalosporin ceftriaxone is consid-ered to be a useful antibiotic due to its good penetrationinto the vitreous compartment [15] Intravitreal vancomycinand ceftazidime are also successfully administrated in somestudies [64 65]

Resistance of K pneumonia to strains that produceextended-spectrum 120573-lactamase (ESBL) had been noted inmany parts of the world [6 9 66] Antibiotics such as120573-lactam for Beta-lactamase inhibitor combinations suchas piperacillintazobactam (TZP) and ampicillinsulbactamhave replaced extended-spectrum cephalosporins (ESCs)to control ESBL prevalence in Korea [67] Recently TZP


Table3Com

paris

onof

CTim

agingcharacteris

ticsb

etweenKL

Aandno

n-KL

Arepo

rted

from

Hon

gKo

ng(38)K

orea

(30)Singapo

re(41)Taiwan

(35)and

China

(1)

Parameters

Hon

gKo

ng(38)

(119899=161)

Korea(

30)(119899=129)

Sing

apore(41)(119899=131)

China(

1)(119899=110)

Taiwan

(35)

(119899=248)

KLA(14

0)Non

-KLA

(21)

Pvalue

KLA(59)

Non

-KLA

(70)

Pvalue

KLA(92)

Non

-KLA

(39)

Pvalue

KLA(73)

Non

-KLA

(37)

Pvalue

KLA(171)

Non

-KLA

(77)

Pvalue

Noof

abscess

001

lt005

Solitary(119899=1)

mdashmdash

mdashmdash

mdashmdash

73(793

)

22(564

)60

(822

)30

(811)

NS

125(731

)45

(584

)Multip

le(119899gt1)

mdashmdash

mdashmdash

mdashmdash

19(207

)17

(436

)13

(178

)

7(189

)NS

46(269

)32

(416

)

Locatio

n0312

001

NS

Right

97(693

)

15(714

)

042

41(695

)

49(700

)76

(826)

sect(615

)

sect47

(644

)24

(649

)lowastNS

128(749

)52

(675

)

Left

31(221

)4(19

1)

038

14(237

)16

(229

)sect

sect11(151

)5(167

)lowastNS

34(19

9)

19(247

)Bo

th12

(86)

2(95)

044

4(68)

5(71

)16

(174

)

15(385

)2(27)lowast

1(27

)lowastNS

9(52)

6(78

)lt572

(421

)lt536

(468

)NS

Size

(cm)

65plusmn28

74plusmn29

019

mdashmdash

mdash73plusmn28

78plusmn28

03574plusmn24

74plusmn32

NS

5ndash1087

(509

)5ndash1037

(481

)

Septations

with

inabscess

0103

001

mdash

Unilocular

mdashmdash

mdash9(153

)19

(271)

5(54)

11(282

)mdash

mdashmdash

mdashmdash

Multilocular

84(60

)13

(619

)

043

50(847

)51

(729

)87

(946

)28

(718

)

41(387

)20

(357

)NS

mdashmdash

Gas-fo

rmationin

abscess

13(93)

2(95)

049

52(897

)

64(914

)

0536

11(282

)6(154

)058

24(329

)5(135

)lt005

7(41

)4(52)

NS

Septalenhancem

ent

mdashmdash

mdash44

(746

)41

(586

)0056

mdashmdash

mdash30

(411)

6(162

)lt005

mdashmdash

mdashRim-enh

ancement

68(486

)12

(571)

023

20(339

)43

(614

)

000

4mdash

mdashmdash

28(384

)12

(324

)NS

mdashmdash

mdashPn

eumob

ilia

9(64)

0(00)

012

mdashmdash

mdash1(11)

5(128

)001

7(96)

3(81

)NS

mdashmdash

mdashTh

rombo

phlebitis

2(14)

1(48

)013

mdashmdash

mdash28

(304

)2(51

)lt001

mdashmdash

mdashmdash

mdashmdash

mdashTh

erewereno

data

inthesereferencessectlocatio

nsof

right

andleftareno

tmentio

nedseparatelyin

reference[41]meansplusmnsta

ndardlowast

therewereotherlocations

ofabscessinadditio

nto

thosementio

nedin

reference[1]


Table4Antibiotic

treatmentinpatie

ntsw

ithKlebsiella

pneumoniaeliver

abscessa

ndStreptococcusm

illeriliver

abscess

KLA

Streptococcusm

illeri

Hon

gKo

ng(38)

(119899=140)

Sing

apore(4)

(119899=109)

Taiwan

(62)

(119899=110)

Turkey

(61)(119899=85)

Hon

gKo

ng(38)

(119899=21)

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Extend

ed-spectrum

penicillinlowast

217

48(343

)mdash

mdashmdash

mdashmdash

4(47)

154

11(524

)First-andsecond

-generation

ceph

alospo

rinssect

217

30(214

)32plusmn13

24(220

)mdash

104(945

)mdash

mdash154

4(19

)

Third

-and

fourth-generation

ceph

alospo

rins998771

217

50(357

)32plusmn13

71(651

)mdash

4(36)

mdash5(59)

154

3(14

3)

Carbapenem

sandmdash

mdash32plusmn13

13(119

)

mdashmdash

mdash42

(494

)

mdashmdash

Aminoglycosid

es

mdashmdash

mdash1(09

)mdash

104(945

)mdash

2(24)

mdashmdash

Quino

lonelowastlowast

mdashmdash

mdashmdash

mdashmdash

mdash11(129

)mdash

mdashlowast

Piperacillin-tazobactam

ticarcillin-cla

vulanatesectcefazolin

998771ceftriaxonecefepim

eand

ertapenemm

erop

enem

am

ikacinlowastlowast

ciprofl

oxacin


Plain scan Arterial phase Parenchymal phase

(a)


(b)


(c)

Figure 1 Comparison of abdominal CT images between KLA and Non-KLA (a) CT images of a 57-year-old male KLA patient withconcomitant diabetesmellitus circular shadow of low and uneven density can be seen in the caudate lobe near the second hepatic portalWitha diameter of 90mm a shadow ofmuch lower density and gas cavities can be seen in the center of the abscess During enhanced scanning themargin and internal septations of abscess show a honeycomb-like structure Intrahepatic bile ducts show slight dilation (b) CT images of a51-year-old female patient with E coli liver abscess irregular low-density lesion with a honeycomb-like structure can be seen in the right lobeof the liver Obvious cystic wall enhancement can be seen during enhanced scanning There is no stenosis or filling defect of hepatic vessels(c) CT images of a 65-year-old female patient with Pseudomonas aeruginosa liver abscess patchy shadow of low-and-even density and clearedge can be seen in the right lobe of the liver By enhanced CT scan the peripheral enhancement is more dramatic than the nonperipheralenhancement Septation is visible inside the abscess and hepatic blood vessels are evenly distributed KLAKlebsiella pneumoniae liver abscessNon-KLA non-Klebsiella pneumonia-induced pyogenic liver abscess

resistance among K pneumonia isolates has been shownas high as 209 (50239) versus 76 (13170) of E coliand the mechanisms for TZP resistance might include thepresence of AmpC producers multiple b-lactamases in indi-vidual organisms of a given isolate and possible TEM-1hyperproducers [66] Drug-resistant K pneumonia is moreprevalent in the DM group than in the non-DM group [68]If a patient presents with the risk factors for infection withESBL-producing organisms carbapenem antibiotics (egimipenem meropenem ertapenem or doripenem) shouldbe recommended before the culture and isolation results areobtained Carbapenem (primarily imipenem) has been foundto be independently associated with lower mortality thanother antibiotics [61]

72 Interventional Therapy Percutaneous drainage waswidely used during the past two decades [6 37 46 69] andthe obvious advantages are the simplicity of treatmentand avoidance of general anesthesia and laparotomy As formultiple abscesses percutaneous drainage usuallymeets witha higher failure rate [47] However a recent retrospectivestudy showed that the treatment with percutaneous

transhepatic drainage demonstrated similar effectivenessfor the patients with multiple abscesses but shorter hospi-talization when compared with surgical drainage groupwhich suggested that percutaneous drainage should alwaysbe undertaken before surgery in terms of its lower morbidityand less cost [69]

Percutaneous drainage includes percutaneous aspirationand percutaneous catheter drainage Yu et al found thatintermittent needle aspiration was probably as effective ascontinuous catheter drainage for the treatment of PLA [46]Due to the solid nature of KLA procedure simplicity patientcomfort and reduced price needle aspiration deserves to beconsidered as a first-line drainage approach Patients withthe following criteria are taken for percutaneous drainage(1) patients who continued to be febrile even after 48ndash72 hof adequate medical treatment (2) liver abscess more than6 cm in size and (3) clinical or ultrasonographic featuressuggesting impending perforation [70]

73 Surgical Intervention Although percutaneous drainagehas replaced surgery as the primary treatment of liver abscess[37 69] the surgery still has its irreplaceable position under


some conditions Surgery drainage is carried out in patientsfalling within the criteria which are as follows (1) thickpus which could not be aspirated (2) patients with multipleliver abscess (3) patients with ongoing sepsis even afterantibiotic therapy and percutaneous drainage (4) patientswith underlying diseases such as the biliary tract disease orthe liver cirrhosis (5) multiloculated abscess (6) abscess inthe left lobe and (7) ruptured abscesses [28 34 36 37 59 6069 71 72]

Recently a case with intraperitoneal rupture of pyogenicliver abscess caused byK pneumoniawas successfully treatedwith hepatectomy combined with antibiotics [34] The solidnature of the abscess and the complicating DIC precludepercutaneous catheter drainage of the abscess This indicatesthat surgical hepatectomy is necessary and useful in KLAtreatment In general surgical drainage has been reserved forpatients who fail to respond to treatment with percutaneousdrainage and antibiotics or who have concurrent intra-abdominal pathology which requires surgical management[47] Thus percutaneous and surgical techniques are notcompeting methods but they have different indicationsand surgery also represents an option for nonresponders topercutaneous treatment

74 Glycemic Control Furthermore glycemic control in dia-betic patients plays an essential role in the clinical featuresof KLA especially in metastatic complications from KLA[49 50]

8 Prognosis

Overall the prognosis is better for patients with KLA than forthose with other bacterial liver abscesses insofar as mortality[16 19 35] and disease relapse [16] Diabetes mellitus andthe K1 serotype were common risk factors for recurrent KLA[51 73] The outlook for patients who develop metastaticinfections especially endophthalmitis is grim [13 15 16]

9 Conclusion

PLA caused by K pneumonia is an emerging infectiousdisease in diabetic patients in Asian countries and areas theUnited States and Europe and it tends to spread globallyStrains of capsule K1 are the most virulent serotypes andare commonly associated with KLA and its complicationsVarious genes contribute to these hypermucoviscous featuresincluding rmpA aerobactin magA kfu and allS whichcan be exploited as a genetic marker for rapid moleculardiagnosis and for treatment of this diseaseThe characteristicsof imaging features contribute to the early diagnosis andpercutaneous intervention combined with an aminoglyco-side plus either an extended-spectrum betalactam suchas piperacillinsulbactam or a second- or third-generationcephalosporin is a timely and effective treatment of KLATheprognosis is better for patients with KLA than for those withother bacterial liver abscesses however KLAswithmetastaticinfections especially endophthalmitis have poor outcomes

Conflict of Interests

The authors have declared that they have no conflict ofinterests

Acknowledgments

The authors would like to thank the National Nature ScienceFoundation of China (Grants nos 81070341 and 81270517) fortheir foundationrsquos support

References

[1] J Li Y Fu J Y Wang et al ldquoEarly diagnosis and therapeuticchoice of Klebsiella pneumoniae liver abscessrdquo Frontiers ofMedicine in China vol 4 no 3 pp 308ndash316 2010

[2] L K Siu C Fung F Chang et al ldquoMolecular typing andvirulence analysis of serotype K1 Klebsiella pneumoniae strainsisolated from liver abscess patients and stool samples fromnoninfectious subjects in Hong Kong Singapore and TaiwanrdquoJournal of Clinical Microbiology vol 49 no 11 pp 3761ndash37652011

[3] D R Chung H Lee M H Park et al ldquoFecal carriage ofserotype K1 Klebsiella pneumoniae ST23 strains closely relatedto liver abscess isolates in Koreans living in Koreardquo EuropeanJournal of Clinical Microbiology and Infectious Diseases vol 31no 4 pp 481ndash486 2011

[4] D S Chan S Archuleta R M Llorin D C Lye and D FisherldquoStandardized outpatientmanagement ofKlebsiella pneumoniaeliver abscessesrdquo International Journal of Infectious Diseases vol17 no 3 pp e185ndashe188 2013

[5] H Hagiya Y Kuroe H Nojima et al ldquoEmphysematous liverabscesses complicated by septic pulmonary emboli in patientswith diabetes two casesrdquo Internal Medicine vol 52 no 1 pp141ndash145 2013

[6] J Rahimian T Wilson V Oram and R S Holzman ldquoPyogenicliver abscess recent trends in etiology and mortalityrdquo ClinicalInfectious Diseases vol 39 no 11 pp 1654ndash1659 2004

[7] E R Lederman and N F Crum ldquoPyogenic liver abscesswith a focus on Klebsiella pneumoniae as a primary pathogenan emerging disease with unique clinical characteristicsrdquo TheAmerican Journal of Gastroenterology vol 100 no 2 pp 322ndash331 2005

[8] P Golia and M Sadler ldquoPyogenic liver abscess Klebsiella as anemerging pathogenrdquo Emergency Radiology vol 13 no 2 pp 87ndash88 2006

[9] M Pastagia and V Arumugam ldquoKlebsiella pneumoniae liverabscesses in a public hospital in Queens New Yorkrdquo TravelMedicine and Infectious Disease vol 6 no 4 pp 228ndash233 2008

[10] J V Pope D L Teich P Clardy and D C McGillicuddyldquoKlebsiella pneumoniae liver abscess an emerging problem inNorth Americardquo Journal of Emergency Medicine vol 41 no 5pp e103ndashe105 2011

[11] D D Sachdev M T Yin J D Horowitz S K Mukkamala SE Lee and A J Ratner ldquoKlebsiella pneumoniae K1 liver abscessand septic endophthalmitis in aUS residentrdquo Journal of ClinicalMicrobiology vol 51 no 3 pp 1049ndash1051 2013

[12] X Nassif J M Fournier J Arondel and P J SansonettildquoMucoid phenotype of Klebsiella pneumoniae is a plasmid-encoded virulence factorrdquo Infection and Immunity vol 57 no2 pp 546ndash552 1989


[13] S K Sobirk C Struve and S G Jacobsson ldquoPrimary Klebsiellapneumoniae liver abscesswithmetastatic spread to lung and eyea North-european case report of an emerging syndromerdquoOpenMicrobiology Journal vol 4 pp 5ndash7 2010

[14] R Moore D O rsquoShea T Geoghegan P W Mallon and GSheehan ldquoCommunity-acquired Klebsiella pneumoniae liverabscess an emerging infection in Ireland and Europerdquo Infectionvol 41 no 1 pp 681ndash686 2013

[15] C P Fung F Y Chang S C Lee et al ldquoA global emergingdisease of Klebsiella pneumoniae liver abscess Is serotype K1 animportant factor for complicated endophthalmitisrdquo Gut vol50 no 3 pp 420ndash424 2002

[16] J H Wang Y Liu S S Lee et al ldquoPrimary liver abscess due toKlebsiella pneumoniae in Taiwanrdquo Clinical Infectious Diseasesvol 26 no 6 pp 1434ndash1438 1998

[17] S C Chang C T Fang P R Hsueh Y C Chen and K T LuhldquoKlebsiella pneumoniae isolates causing liver abscess in TaiwanrdquoDiagnostic Microbiology and Infectious Disease vol 37 no 4 pp279ndash284 2000

[18] C T Fang S Y Lai W C Yi P R Hsueh K L Liu and SC Chang ldquoKlebsiella pneumoniae genotype K1 an emergingpathogen that causes septic ocular or central nervous systemcomplications from pyogenic liver abscessrdquo Clinical InfectiousDiseases vol 45 no 3 pp 284ndash293 2007

[19] F C Tsai Y T Huang L Y Chang and J T Wang ldquoPyogenicliver abscess as endemic disease Taiwanrdquo Emerging InfectiousDiseases vol 14 no 10 pp 1592ndash1600 2008

[20] C P Fung Y T Lin J C Lin et al ldquoKlebsiella pneumoniaein gastrointestinal tract and pyogenic liver abscessrdquo EmergingInfectious Diseases vol 18 no 8 pp 1322ndash1325 2012

[21] J J Keller M C Tsai C C Lin Y C Lin and H C Lin ldquoRiskof infections subsequent to pyogenic liver abscess a nationwidepopulation-based studyrdquo Clinical Microbiology and Infectionvol 19 no 8 pp 717ndash722 2013

[22] Y T Lin F D Wang P F Wu and C P Fung ldquoKlebsiellapneumoniae liver abscess in diabetic patients association ofglycemic control with the clinical characteristicsrdquo BMC Infec-tious Diseases vol 13 no 1 article 56 2013

[23] Y Keynan J A Karlowsky T Walus and E RubinsteinldquoPyogenic liver abscess caused by hypermucoviscous Klebsiellapneumoniaerdquo Scandinavian Journal of Infectious Diseases vol39 no 9 pp 828ndash830 2007

[24] J F Turton H Englender S N Gabriel S E Turton ME Kaufmann and T L Pitt ldquoGenetically similar isolates ofKlebsiella pneumoniae serotype K1 causing liver abscesses inthree continentsrdquo Journal of Medical Microbiology vol 56 no5 pp 593ndash597 2007

[25] T C Y Pang T Fung J Samra T J Hugh and R C SmithldquoPyogenic liver abscess an audit of 10 yearsrsquo experiencerdquoWorldJournal of Gastroenterology vol 17 no 12 pp 1622ndash1630 2011

[26] A Vila A Cassata H Pagella et al ldquoAppearance of Klebsiellapneumoniae liver abscess syndrome in Argentina case reportand review of molecular mechanisms of pathogenesisrdquo OpenMicrobiology Journal vol 5 pp 107ndash113 2011

[27] S C Chen WWu C H Yeh et al ldquoComparison of Escherichiacoli and Klebsiella pneumoniae liver abscessesrdquo The AmericanJournal of the Medical Sciences vol 334 no 2 pp 97ndash105 2007

[28] H J Mischinger H Hauser H Rabl et al ldquoPyogenic liverabscess studies of therapy and analysis of risk factorsrdquo WorldJournal of Surgery vol 18 no 6 pp 852ndash858 1994

[29] J K Kim D R Chung S H Wie J H Yoo and S W ParkldquoRisk factor analysis of invasive liver abscess caused by the K1serotype Klebsiella pneumoniaerdquo European Journal of ClinicalMicrobiology and Infectious Diseases vol 28 no 1 pp 109ndash1112009

[30] N K Lee S Kim JW Lee et al ldquoCT differentiation of pyogenicliver abscesses caused by Klebsiella pneumoniae versus non-Klebsiella pneumoniaerdquoTheBritish Journal of Radiology vol 84no 1002 pp 518ndash525 2011

[31] S C Chen C C Huang S J Tsai et al ldquoSeverity of diseaseas main predictor for mortality in patients with pyogenic liverabscessrdquo The American Journal of Surgery vol 198 no 2 pp164ndash172 2009

[32] J Fierer ldquoBiofilm formation and Klebsiella pneumoniae liverabscess true true and unrelatedrdquo Virulence vol 3 no 3 pp241ndash242 2012

[33] W K Huang J W Chang L C See et al ldquoHigher rate ofcolorectal cancer among patients with pyogenic liver abscesswith Klebsiella pneumoniae than those without an 11-yearfollow-up studyrdquo Colorectal Disease vol 14 no 12 pp e794ndashe801 2012

[34] K Morii A Kashihara S Miura et al ldquoSuccessful hepatectomyfor intraperitoneal rupture of pyogenic liver abscess caused byKlebsiella pneumoniaerdquoClinical Journal of Gastroenterology vol5 no 2 pp 136ndash140 2012

[35] C C Yang C H Yen M W Ho and J H Wang ldquoComparisonof pyogenic liver abscess caused by non-Klebsiella pneumoniaeand Klebsiella pneumoniaerdquo Journal of Microbiology Immunol-ogy and Infection vol 37 no 3 pp 176ndash184 2004

[36] S Basu ldquoKlebsiella pneumoniae an emerging pathogen ofpyogenic liver abscessrdquo Oman Medical Journal vol 24 no 2pp 131ndash133 2009

[37] J J Mezhir Y Fong L M Jacks et al ldquoCurrent management ofpyogenic liver abscess surgery is now second-line treatmentrdquoJournal of the American College of Surgeons vol 210 no 6 pp975ndash983 2010

[38] S T Law and M K K Li ldquoIs there any difference in pyogenicliver abscess caused by Streptococcus milleri and Klebsiellaspp Retrospective analysis over a 10-year period in a regionalhospitalrdquo Journal of Microbiology Immunology and Infectionvol 46 no 1 pp 11ndash18 2013

[39] S U Shin C M Park Y Lee E C Kim S J Kim and J MGoo ldquoClinical and radiological features of invasive Klebsiellapneumoniae liver abscess syndromerdquo Acta Radiologica vol 54no 5 pp 557ndash563 2013

[40] J Y Hui M K W Yang D H Y Cho et al ldquoPyogenic liverabscesses caused by Klebsiella pneumoniae US appearance andaspiration findingsrdquo Radiology vol 242 no 3 pp 769ndash7762007

[41] H S Alsaif S K Venkatesh D S G Chan and S ArchuletaldquoCT appearance of pyogenic liver abscesses caused by Klebsiellapneumoniaerdquo Radiology vol 260 no 1 pp 129ndash138 2011

[42] J R Anstey T N Fazio D L Gordon et al ldquoCommunity-acquired Klebsiella pneumoniae liver abscessesmdashan ldquoemergingdiseaserdquo in AustraliardquoMedical Journal of Australia vol 193 no9 pp 543ndash545 2010

[43] Y J Su Y C Lai Y C Lin and Y H Yeh ldquoTreatment andprognosis of pyogenic liver abscessrdquo International Journal ofEmergency Medicine vol 3 no 4 pp 381ndash384 2010

[44] M El-Shabrawi and F Hassanin ldquoPyogenic liver abscessrdquo inTextbook of Clinical Pediatrics vol 3 pp 2109ndash2112 2012


[45] T Tatsuta TWada D Chinda et al ldquoA case of gas-forming liverabscesswith diabetesmellitusrdquo InternalMedicine vol 50 no 20pp 2329ndash2332 2011

[46] S C H Yu S S M HoW Y Lau et al ldquoTreatment of pyogenicliver abscess prospective randomized comparison of catheterdrainage and needle aspirationrdquo Hepatology vol 39 no 4 pp932ndash938 2004

[47] A A Malik S U Bari K A Rouf and K A Wani ldquoPyogenicliver abscess changing patterns in approachrdquo World Journal ofGastrointestinal Surgery vol 2 no 12 pp 395ndash401 2010

[48] L K Siu K M Yeh J C Lin C P Fung and F Y ChangldquoKlebsiella pneumoniae liver abscess a new invasive syndromerdquoThe Lancet Infectious Diseases vol 12 no 11 pp 881ndash887 2012

[49] Y T Lin L K Siu J C Lin et al ldquoSeroepidemiology ofKlebsiella pneumoniae colonizing the intestinal tract of healthyChinese and overseas Chinese adults in Asian countriesrdquo BMCMicrobiology vol 12 article 13 2012

[50] J C Lin L K Siu C P Fung et al ldquoImpaired phagocytosisof capsular serotypes K1 or K2 Klebsiella pneumoniae in type 2diabetes mellitus patients with poor glycemic controlrdquo Journalof Clinical Endocrinology and Metabolism vol 91 no 8 pp3084ndash3087 2006

[51] Y S Yang L K Siu K M Yeh et al ldquoRecurrent Klebsiellapneumoniae liver abscess clinical and microbiological charac-teristicsrdquo Journal of Clinical Microbiology vol 47 no 10 pp3336ndash3339 2009

[52] W L Yu W C Ko K C Cheng C C Lee C C Lai and YC Chuang ldquoComparison of prevalence of virulence factors forKlebsiella pneumoniae liver abscesses between isolates with cap-sular K1K2 and non-K1K2 serotypesrdquoDiagnostic Microbiologyand Infectious Disease vol 62 no 1 pp 1ndash6 2008

[53] C RHsu T L Lin Y C ChenH C Chou and J TWang ldquoTherole of Klebsiella pneumoniae rmpA in capsular polysaccharidesynthesis and virulence revisitedrdquoMicrobiology vol 157 part 12pp 3446ndash3457 2011

[54] C T Fang Y P Chuang C T Shun S C Chang and J TWangldquoAnovel virulence gene inKlebsiella pneumoniae strains causingprimary liver abscess and septic metastatic complicationsrdquoJournal of Experimental Medicine vol 199 no 5 pp 697ndash7052004

[55] X Nassif and P J Sansonetti ldquoCorrelation of the virulence ofKlebsiella pneumoniaeK1 and K2 with the presence of a plasmidencoding aerobactinrdquo Infection and Immunity vol 54 no 3 pp603ndash608 1986

[56] L C Ma C Fang C Z Lee C T Shun and J T WangldquoGenomic heterogeneity in Klebsiella pneumoniae strains isassociated with primary pyogenic liver abscess and metastaticinfectionrdquo Journal of Infectious Diseases vol 192 no 1 pp 117ndash128 2005

[57] M C Wu Y C Chen T L Lin P F Hsieh and J T WangldquoCellobiose-specific phosphotransferase system of Klebsiellapneumoniae and its importance in biofilm formation andvirulencerdquo Infection and Immunity vol 80 no 7 pp 2464ndash24722012

[58] H C Chou C Z Lee L C Ma C T Fang S C Chang andJ T Wang ldquoIsolation of a chromosomal region of Klebsiellapneumoniae associated with allantoin metabolism and liverinfectionrdquo Infection and Immunity vol 72 no 7 pp 3783ndash37922004

[59] M Ukikusa T Inomoto T Kitai et al ldquoPneumoperitoneumfollowing the spontaneous rupture of a gas-containing pyogenic

liver abscess report of a caserdquo Surgery Today vol 31 no 1 pp76ndash79 2001

[60] J A Alvarez Perez J J Gonzalez R F Baldonedo et al ldquoClinicalcourse treatment and multivariate analysis of risk factors forpyogenic liver abscessrdquo The American Journal of Surgery vol181 no 2 pp 177ndash186 2001

[61] D L Paterson W Ko A von Gottberg et al ldquoAntibiotictherapy for Klebsiella pneumoniae bacteremia implicationsof production of extended-spectrum 120573-lactamasesrdquo ClinicalInfectious Diseases vol 39 no 1 pp 31ndash37 2004

[62] S S Lee Y S Chen H C Tsai et al ldquoPredictors of septicmetastatic infection and mortality among patients with Kleb-siella pneumoniae liver abscessrdquoClinical Infectious Diseases vol47 no 5 pp 642ndash650 2008

[63] H P Cheng L K Siu and F Y Chang ldquoExtended-spectrumcephalosporin compared to cefazolin for treatment ofKlebsiellapneumoniae-caused liver abscessrdquo Antimicrobial Agents andChemotherapy vol 47 no 7 pp 2088ndash2092 2003

[64] M L Durand ldquoEndophthalmitisrdquo Clinical Microbiology andInfection vol 19 no 3 pp 227ndash234 2013

[65] A H Kashani and D Eliott ldquoThe emergence of Klebsiellapneumoniae endogenous endophthalmitis in the USA basicand clinical advancesrdquo Journal of Ophthalmic Inflammation andInfection vol 3 no 1 article 28 2013

[66] J Lee C E Oh E H Choi and H J Lee ldquoThe impact ofthe increased use of piperacillintazobactam on the selection ofantibiotic resistance among invasive Escherichia coli and Kleb-siella pneumoniae isolatesrdquo International Journal of InfectiousDiseases vol 17 no 8 pp e638ndashe643 2013

[67] J Lee H Pai Y K Kim et al ldquoControl of extended-spectrum 120573-lactamase-producingEscherichia coli andKlebsiella pneumoniaein a childrenrsquos hospital by changing antimicrobial agent usagepolicyrdquo Journal of Antimicrobial Chemotherapy vol 60 no 3pp 629ndash637 2007

[68] L T Tian K Yao X Y Zhang et al ldquoLiver abscesses in adultpatients with and without diabetes mellitus an analysis ofthe clinical characteristics features of the causative pathogensoutcomes and predictors of fatality a report based on a largepopulation retrospective study in Chinardquo Clinical Microbiologyand Infection vol 18 no 9 pp E314ndashE330 2012

[69] G Ferraioli A Garlaschelli D Zanaboni et al ldquoPercutaneousand surgical treatment of pyogenic liver abscesses observationover a 21-year period in 148 patientsrdquo Digestive and LiverDisease vol 40 no 8 pp 690ndash696 2008

[70] G Porras-RamirezMHHernandez-Herrera and J D Porras-Hernandez ldquoAmebic hepatic abscess in childrenrdquo Journal ofPediatric Surgery vol 30 no 5 pp 662ndash664 1995

[71] W W Hope D V Vrochides W L Newcomb W W Mayo-Smith and D A Iannitti ldquoOptimal treatment of hepaticabscessrdquo American Surgeon vol 74 no 2 pp 178ndash182 2008

[72] A Onder M Kapan A Boyuk et al ldquoSurgical managementof pyogenic liver abscessrdquo European Review for Medical andPharmacological Sciences vol 15 no 10 pp 1182ndash1186 2011

[73] F C Yeh K M Yeh L K Siu et al ldquoIncreasing opsonizing andkilling effect of serum from patients with recurrent K1Klebsiellapneumoniae liver abscessrdquo Journal of Microbiology Immunologyand Infection vol 45 no 2 pp 141ndash146 2012

Submit your manuscripts athttpwwwhindawicom

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Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


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of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



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The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

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ObesityJournal of



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Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


have occurred in the United States [6ndash11] and Europe [12ndash14] However differing from the much higher incidence ofKLA in Asian countries and areas [1ndash5] especially the highestincidence in Taiwan that ranges from 80 to 90 [16 19]a relatively low incidence of 30ndash40 is estimated in theUS [6 9] The exact cause for the increasing prevalence ofKLA in Asia is not known but it may be related to the largepopulation of Asia the host susceptibility to infection thedifference in carriage rates and the environmental factorsor the emergence of a distinct strain of K pneumonia andan increased propensity to cause liver abscesses might bepotentially contributing to such a geographical difference inthe epidemiology of K pneumonia infection For exampleChung et al had noted that people of Korean ethnicitywho had lived in countries other than Korea had a lowerproportion of carrying serotype K1 of K pneumonia strainsthan those who lived in Korea [3] These findings indicate apotential role of the environmental factors in the intestinalcolonization of these strains

The middle-to-older-aged patients are at higher risk ofdeveloping KLA The peak incidence of the disease is 55ndash60 years old [4 6 7 9 16 19 40 41] Reports of KLA inchildren are rare [44] Male dominance is found in patientswith KLA and the male-to-female ratio is approximately 15ndash25 1 [4 7 9 14 16 19 21 35 36 38 41] (Table 1)

The mortality rate of KLA is lower than that of the Non-KLA [16 19 35] ranging from 2 to 18 [6 7 15 16 1819 35 36 38 40 46ndash48] Owing to the improvement ofdiagnosis and peoplersquos awareness of treatment the mortalityrate decreases

3 Etiology

KLAs are usually primary and cryptogenic [3 6 17 27 29ndash34] and cryptogenic invasive KLAs are frequently associatedwith diabetes mellitus [22] but they does not show anyclear association with peritoneal sources of infections suchas hepatobiliary obstruction pancreatitis enterocolitis ormalignant diseases

Some studies manifested that translocation from thegastrointestinal tract maybe the most likely route by whichK pneumonia caused liver abscess [3 20] Fung et al demon-strated that gastrointestinal carriage was a predisposingfactor for liver abscess [20] Furthermore they also foundthat patients with KLA and healthy carriers had identicalpulsed-field gel electrophoresis (PFGE) profileswith the samevirulence-associated genes and similar LD50 values In arecent investigation Lin et al reported a fecal carriage rate ofK pneumonia in healthy adults of 75 and high prevalence(23) of serotype K1K2 isolates among typical strains inTaiwan [49] K pneumonia can colonize the gastrointestinaltract of humans which suggests that colonization by theK pneumoniae strains precedes invasion of the intestinalmucosa and portal venous flowor ascending biliary infectionwhich is followed by the development of liver abscess

Several studies have found that capsule K1 and K2 werethe most two common causes of KLA (Table 2) K1 isolatesoccur at a significantly higher frequency than those of all

other serotypes especially in patients with diabetes mellitus[15] A recent case-control study performed by Kim et alsuggested that diabetes mellitus was an important underlyingfactor that correlates with a high incidence of K1 serotype inKLA [29] Poor glycemic control plays an important role inimpairing the neutrophil phagocytic function of patients withK1K2-typeKLAwhereas it does not significantly affect thoseof patients with non-K1K2 KLA [50] Capsule k1 serotypeis found to express the hypermucoviscous phenotypes whichcan produce vast amounts of extracapsular polysaccharideconstituting a mucoviscous web that protects these strainsfrom phagocytosis by neutrophils and from serum killing bycomplement [2 13 51] In addition in vitro serumassays showa significantly higher serum resistance on average for K1 thanK2 strains indicating that K1 and K2 strains have unequalvirulence [18] Recently most isolates of serotype K1 fromKLA patients belong to ST23 which is the most prevalentsequence type among serotype K1 isolates [2 24 26]

4 Bacterial Genes and Pathogenesis

A number of bacterial genes which are significantly corre-lated with the high virulence of the invasive strains [2 24 2652] have been proposed or suggested to play key roles in thepathogenesis of hepatovirulent KLA (Table 2)

The rmpA gene (a regulator of the mucoid phenotype)which is a transcriptional activator of the cps genes and func-tions as a positive regulator of extracapsular polysaccharidesynthesis has a strong association with hypermucoid strainsin PLA [18 52 53] Loss of this regulator will downregulatecapsule synthesis and knockout of the rmpA gene candecrease virulence in mouse lethality tests by 1000 folds [12]leading to the loss of phagocytic resistance and the mucoidphenotype Hsu et al found a correlation of rmpAA2with sixPLA-related capsular types (K1 K2 K5 K54 K57 and KN1)However the correlation of rmpAA2with K1 strains from theWest was less obvious than with the strains from Asia [53]

On the other hand magA a chromosomal gene whichis located in the cps (capsular polysaccharide synthesis)operon has been recently renamed wzyKpK1 and has beenshown to be specific for K1 capsule formation [26] MagAcan contribute to capsular polysaccharide formation and itis identified as an important virulence gene in invasive Kpneumoniae strains causing primary liver abscess and septicmetastatic complications [54] MagAmutants are also shownto lose the potential to produce this protective mucus andbecame susceptible to human serum and phagocytosis

The growth of bacteria in host tissues is limited notonly by host defense mechanisms but also by their supply ofavailable ironMany bacteria attempt to secure their supply ofiron in the host by secreting high-affinity iron chelators calledsiderophores like aerobactin Aerobactin an iron chelatorcalled iron siderophore can increase virulence in mouselethality tests by 100 folds [55]

A 20 kb chromosomal region including an iron uptakesystem (kfu) and a phosphoenolpyruvate sugar phospho-transferase system (PTS) was found to be presented in mostof the genomes of the tissue-invasive K pneumoniae strains


ble1Dem

ograph

icclin

icalcharacteris

ticsa

ndtre

atmento

fpatientsw

ithKlebsiella

pneumoniaeliver

abscessesfrom

case

repo

rts

Case

Age

Sex

Race

Und

erlyingdiseases

Symptom

Locatio

nof

medicaltherapy

Outcome

Reference

164

FFilip

ino

Diabetesm

ellitus

thrombo

cytosis

Feverrig

orsnausea

andmyalgias

Rightlob

e

Piperacilin

-tazobactam

(337

gQ6h

)+gentam

icin

(400

mgq

d)ceft

riaxone

(2givqd


mgivfour

times

daily)

follo

wed

bylevoflo


wks

Survived

[7]

271

MCa

ucasian

Coron

aryartery

disease

Feverabdo

minal

painand

hypo

tension

Leftlobe

Cefotetan

(2gBID)+

orallevoflo

xacin(500

mgqd

)for8

wks

Survived

[7]

353

MCa

ucasian

Mitralvalvep

rolapse

and

hypercho

leste

rolemia

Feverrig

orsfatig

ue

malaisenight

sweats

andtooth

pain

Leftlobe

Ceft

riaxone

+metronidazolefor4

wksgentamicin

for2

wksfollowe

dby

oralciprofl

oxacin

for1

mon

thSurvived

[7]

464

FFilip

ino

Pepticulcerd

isease

coronary

artery

diseaseand

hypertensio

n

Feverrig

htabdo

minalpainand

anorexia

Leftlobe

Ciprofl

oxacin

(400

mgiv

bid)

+metronidazole

(500

mgiv

tid)follo

wedby

oralciprofl

oxacin

+metronidazolefor6

wks

Survived

[7]

556

MFilip

ino

Non

eFeverchillsnight

sweats

epigastric

painand

nausea

Rightlob

e


(q6h

)+metronidazole

(500

mgq8h)gentamicin

(180

mgq18h

)follo

wed

byorallevoflo

xacin(500

mgqd

)+metronidazole

(500

mgtid

)for

6wks

Survived

[7]

659

FFilip

ino

Diabetesm

ellitus

Feverchills

anorexiaand

fatig

ueLeftlobe


(337

5gq6h

)+metronidazole(500

mgq8h)ceft

riaxone

(2gday)

+metronidazole(500

mgq8h)

for4

wksfollowed

byorallevoflo

xacin(500

mgday)

for3

mon

ths

Survived

[7]

755

MArgentin

ian

Non

eFevera

ndfatig

ueNR

Ceft

riaxone

+metronidazole

follo

wed

byoral

ciprofl

oxacin

for6

wkspercutaneou

sdrainage

Survived

[26]

847

FOmani

Non

e

Feverchillsrig

ors

mild

coug

hpo

ororalintakeand

inabilityto

walk

Rightlob

eAu

gmentin

(2givq6

h)+gentam

icin

(17gIV

q8h)

for3

wkscatheterd

rainage

Survived

[18]

958

FOmani

Diabetesm

illitu

sFevermalaiseand

nausea

Rightlob

e

Amikacin

(1gIV

q12h)+

cefta

zidime(15

gIV

q8h

for5

days)follo

wed

byciprofl

oxacin

(05gIV

q12h

for12d


(45giv

q8h)

for15d

ays

Survived

[18]

1062

MIrish

Perip

heralvascular

diseasea

ndexcess

alcoho

lintake

Abdo

minalpain

anorexiaandnausea

NR


(45givq8h)

for15d

ays

Survived

[14]

1140

MFilip

ino

Diabetesm

ellitus

Feverpo

lydipsia

andpo

lyuria

Rightlob

eCeft

riaxone

(2givqd

)oralciprofl

oxacin

for6

9days

percutaneous

drainageintraveno

usgentam

icinand

ciprofl

oxacin

(400

mgivbid)

for5

days

Survived

[14]

1255

MCh

inese

Diabetesm

ellitus

Vomiting

abdo

minalpain

feverandrig

ors

Rightlob

e

Oralciproflo

xacinfor3

6daysoralceph

alexin

for


cid(12giv

tid)+

gentam

icin

(320

mgday)

+metronidazole(500

mg

ivtid

)follo

wed

byceftriaxone

(2gdaysdotiv)+

oral

metronidazole(400

mgbid)percutaneou

sdrainage

Survived

[14]


Table1Con

tinued

Case

Age

Sex

Race

Und

erlyingdiseases

Symptom

Locatio

nof

medicaltherapy

Outcome

Reference

1358

MJapanese

Diabetesm

ellitus

Malaise

Rightlob

eMerop

enem

(1givq12h)for

6dayscefm

etazole(

2givQ8h

)oralcefcapenep

ivoxil(100

mgtid

)and

antib

iotic

treatmentfor

30days

Survived

[5]

1461

FJapanese

Diabetesm

ellitus

Feverchillsanda

slighth

eadache

NR

Merop

enem

(1giv

q8h)

+lin

ezolid

(600

mgiv

q12h

)changedto

ceftriaxone

(2gq12h

)for

20days

follo

wed

byoralceph

alexin

(250

mgq6

h)for3

1days

Survived

[5]

1543

MJapanese

Non

eRight

hypo

chon

driaca

ndepigastricpain

Rightlob

eMerop

enem

(1gd

ayiv)for

15days

+IV

insulin

mgdayandoralciprofl

oxacin

(400

mgday)

for

50days

Survived

[45]

NR

notreported






















7 Therapy








Table3Com

paris

onof

CTim

agingcharacteris

ticsb

etweenKL

Aandno

n-KL

Arepo

rted

from

Hon

gKo

ng(38)K

orea

(30)Singapo

re(41)Taiwan

(35)and

China

(1)

Parameters

Hon

gKo

ng(38)

(119899=161)

Korea(

30)(119899=129)

Sing

apore(41)(119899=131)

China(

1)(119899=110)

Taiwan

(35)

(119899=248)

KLA(14

0)Non

-KLA

(21)

Pvalue

KLA(59)

Non

-KLA

(70)

Pvalue

KLA(92)

Non

-KLA

(39)

Pvalue

KLA(73)

Non

-KLA

(37)

Pvalue

KLA(171)

Non

-KLA

(77)

Pvalue

Noof

abscess

001

lt005

Solitary(119899=1)

mdashmdash

mdashmdash

mdashmdash

73(793

)

22(564

)60

(822

)30

(811)

NS

125(731

)45

(584

)Multip

le(119899gt1)

mdashmdash

mdashmdash

mdashmdash

19(207

)17

(436

)13

(178

)

7(189

)NS

46(269

)32

(416

)

Locatio

n0312

001

NS

Right

97(693

)

15(714

)

042

41(695

)

49(700

)76

(826)

sect(615

)

sect47

(644

)24

(649

)lowastNS

128(749

)52

(675

)

Left

31(221

)4(19

1)

038

14(237

)16

(229

)sect

sect11(151

)5(167

)lowastNS

34(19

9)

19(247

)Bo

th12

(86)

2(95)

044

4(68)

5(71

)16

(174

)

15(385

)2(27)lowast

1(27

)lowastNS

9(52)

6(78

)lt572

(421

)lt536

(468

)NS

Size

(cm)

65plusmn28

74plusmn29

019

mdashmdash

mdash73plusmn28

78plusmn28

03574plusmn24

74plusmn32

NS

5ndash1087

(509

)5ndash1037

(481

)

Septations

with

inabscess

0103

001

mdash

Unilocular

mdashmdash

mdash9(153

)19

(271)

5(54)

11(282

)mdash

mdashmdash

mdashmdash

Multilocular

84(60

)13

(619

)

043

50(847

)51

(729

)87

(946

)28

(718

)

41(387

)20

(357

)NS

mdashmdash

Gas-fo

rmationin

abscess

13(93)

2(95)

049

52(897

)

64(914

)

0536

11(282

)6(154

)058

24(329

)5(135

)lt005

7(41

)4(52)

NS

Septalenhancem

ent

mdashmdash

mdash44

(746

)41

(586

)0056

mdashmdash

mdash30

(411)

6(162

)lt005

mdashmdash

mdashRim-enh

ancement

68(486

)12

(571)

023

20(339

)43

(614

)

000

4mdash

mdashmdash

28(384

)12

(324

)NS

mdashmdash

mdashPn

eumob

ilia

9(64)

0(00)

012

mdashmdash

mdash1(11)

5(128

)001

7(96)

3(81

)NS

mdashmdash

mdashTh

rombo

phlebitis

2(14)

1(48

)013

mdashmdash

mdash28

(304

)2(51

)lt001

mdashmdash

mdashmdash

mdashmdash

mdashTh

erewereno

data


nsof

right

andleftareno

tmentio

nedseparatelyin


ndardlowast


ofabscessinadditio

nto

thosementio

nedin

reference[1]


Table4Antibiotic

treatmentinpatie

ntsw

ithKlebsiella

pneumoniaeliver

abscessa

ndStreptococcusm

illeriliver

abscess

KLA

Streptococcusm

illeri

Hon

gKo

ng(38)

(119899=140)

Sing

apore(4)

(119899=109)

Taiwan

(62)

(119899=110)

Turkey

(61)(119899=85)

Hon

gKo

ng(38)

(119899=21)

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Extend

ed-spectrum

penicillinlowast

217

48(343

)mdash

mdashmdash

mdashmdash

4(47)

154

11(524

)First-andsecond

-generation

ceph

alospo

rinssect

217

30(214

)32plusmn13

24(220

)mdash

104(945

)mdash

mdash154

4(19

)

Third

-and

fourth-generation

ceph

alospo

rins998771

217

50(357

)32plusmn13

71(651

)mdash

4(36)

mdash5(59)

154

3(14

3)

Carbapenem

sandmdash

mdash32plusmn13

13(119

)

mdashmdash

mdash42

(494

)

mdashmdash

Aminoglycosid

es

mdashmdash

mdash1(09

)mdash

104(945

)mdash

2(24)

mdashmdash

Quino

lonelowastlowast

mdashmdash

mdashmdash

mdashmdash

mdash11(129

)mdash

mdashlowast


ticarcillin-cla



eand

ertapenemm

erop

enem

am

ikacinlowastlowast

ciprofl

oxacin



(a)


(b)


(c)











8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















ble1Dem

ograph

icclin

icalcharacteris

ticsa

ndtre

atmento

fpatientsw

ithKlebsiella

pneumoniaeliver

abscessesfrom

case

repo

rts

Case

Age

Sex

Race

Und

erlyingdiseases

Symptom

Locatio

nof

medicaltherapy

Outcome

Reference

164

FFilip

ino

Diabetesm

ellitus

thrombo

cytosis

Feverrig

orsnausea

andmyalgias

Rightlob

e

Piperacilin

-tazobactam

(337

gQ6h

)+gentam

icin

(400

mgq

d)ceft

riaxone

(2givqd


mgivfour

times

daily)

follo

wed

bylevoflo


wks

Survived

[7]

271

MCa

ucasian

Coron

aryartery

disease

Feverabdo

minal

painand

hypo

tension

Leftlobe

Cefotetan

(2gBID)+

orallevoflo

xacin(500

mgqd

)for8

wks

Survived

[7]

353

MCa

ucasian

Mitralvalvep

rolapse

and

hypercho

leste

rolemia

Feverrig

orsfatig

ue

malaisenight

sweats

andtooth

pain

Leftlobe

Ceft

riaxone

+metronidazolefor4

wksgentamicin

for2

wksfollowe

dby

oralciprofl

oxacin

for1

mon

thSurvived

[7]

464

FFilip

ino

Pepticulcerd

isease

coronary

artery

diseaseand

hypertensio

n

Feverrig

htabdo

minalpainand

anorexia

Leftlobe

Ciprofl

oxacin

(400

mgiv

bid)

+metronidazole

(500

mgiv

tid)follo

wedby

oralciprofl

oxacin

+metronidazolefor6

wks

Survived

[7]

556

MFilip

ino

Non

eFeverchillsnight

sweats

epigastric

painand

nausea

Rightlob

e


(q6h

)+metronidazole

(500

mgq8h)gentamicin

(180

mgq18h

)follo

wed

byorallevoflo

xacin(500

mgqd

)+metronidazole

(500

mgtid

)for

6wks

Survived

[7]

659

FFilip

ino

Diabetesm

ellitus

Feverchills

anorexiaand

fatig

ueLeftlobe


(337

5gq6h

)+metronidazole(500

mgq8h)ceft

riaxone

(2gday)

+metronidazole(500

mgq8h)

for4

wksfollowed

byorallevoflo

xacin(500

mgday)

for3

mon

ths

Survived

[7]

755

MArgentin

ian

Non

eFevera

ndfatig

ueNR

Ceft

riaxone

+metronidazole

follo

wed

byoral

ciprofl

oxacin

for6

wkspercutaneou

sdrainage

Survived

[26]

847

FOmani

Non

e

Feverchillsrig

ors

mild

coug

hpo

ororalintakeand

inabilityto

walk

Rightlob

eAu

gmentin

(2givq6

h)+gentam

icin

(17gIV

q8h)

for3

wkscatheterd

rainage

Survived

[18]

958

FOmani

Diabetesm

illitu

sFevermalaiseand

nausea

Rightlob

e

Amikacin

(1gIV

q12h)+

cefta

zidime(15

gIV

q8h

for5

days)follo

wed

byciprofl

oxacin

(05gIV

q12h

for12d


(45giv

q8h)

for15d

ays

Survived

[18]

1062

MIrish

Perip

heralvascular

diseasea

ndexcess

alcoho

lintake

Abdo

minalpain

anorexiaandnausea

NR


(45givq8h)

for15d

ays

Survived

[14]

1140

MFilip

ino

Diabetesm

ellitus

Feverpo

lydipsia

andpo

lyuria

Rightlob

eCeft

riaxone

(2givqd

)oralciprofl

oxacin

for6

9days

percutaneous

drainageintraveno

usgentam

icinand

ciprofl

oxacin

(400

mgivbid)

for5

days

Survived

[14]

1255

MCh

inese

Diabetesm

ellitus

Vomiting

abdo

minalpain

feverandrig

ors

Rightlob

e

Oralciproflo

xacinfor3

6daysoralceph

alexin

for


cid(12giv

tid)+

gentam

icin

(320

mgday)

+metronidazole(500

mg

ivtid

)follo

wed

byceftriaxone

(2gdaysdotiv)+

oral

metronidazole(400

mgbid)percutaneou

sdrainage

Survived

[14]


Table1Con

tinued

Case

Age

Sex

Race

Und

erlyingdiseases

Symptom

Locatio

nof

medicaltherapy

Outcome

Reference

1358

MJapanese

Diabetesm

ellitus

Malaise

Rightlob

eMerop

enem

(1givq12h)for

6dayscefm

etazole(

2givQ8h

)oralcefcapenep

ivoxil(100

mgtid

)and

antib

iotic

treatmentfor

30days

Survived

[5]

1461

FJapanese

Diabetesm

ellitus

Feverchillsanda

slighth

eadache

NR

Merop

enem

(1giv

q8h)

+lin

ezolid

(600

mgiv

q12h

)changedto

ceftriaxone

(2gq12h

)for

20days

follo

wed

byoralceph

alexin

(250

mgq6

h)for3

1days

Survived

[5]

1543

MJapanese

Non

eRight

hypo

chon

driaca

ndepigastricpain

Rightlob

eMerop

enem

(1gd

ayiv)for

15days

+IV

insulin

mgdayandoralciprofl

oxacin

(400

mgday)

for

50days

Survived

[45]

NR

notreported






















7 Therapy








Table3Com

paris

onof

CTim

agingcharacteris

ticsb

etweenKL

Aandno

n-KL

Arepo

rted

from

Hon

gKo

ng(38)K

orea

(30)Singapo

re(41)Taiwan

(35)and

China

(1)

Parameters

Hon

gKo

ng(38)

(119899=161)

Korea(

30)(119899=129)

Sing

apore(41)(119899=131)

China(

1)(119899=110)

Taiwan

(35)

(119899=248)

KLA(14

0)Non

-KLA

(21)

Pvalue

KLA(59)

Non

-KLA

(70)

Pvalue

KLA(92)

Non

-KLA

(39)

Pvalue

KLA(73)

Non

-KLA

(37)

Pvalue

KLA(171)

Non

-KLA

(77)

Pvalue

Noof

abscess

001

lt005

Solitary(119899=1)

mdashmdash

mdashmdash

mdashmdash

73(793

)

22(564

)60

(822

)30

(811)

NS

125(731

)45

(584

)Multip

le(119899gt1)

mdashmdash

mdashmdash

mdashmdash

19(207

)17

(436

)13

(178

)

7(189

)NS

46(269

)32

(416

)

Locatio

n0312

001

NS

Right

97(693

)

15(714

)

042

41(695

)

49(700

)76

(826)

sect(615

)

sect47

(644

)24

(649

)lowastNS

128(749

)52

(675

)

Left

31(221

)4(19

1)

038

14(237

)16

(229

)sect

sect11(151

)5(167

)lowastNS

34(19

9)

19(247

)Bo

th12

(86)

2(95)

044

4(68)

5(71

)16

(174

)

15(385

)2(27)lowast

1(27

)lowastNS

9(52)

6(78

)lt572

(421

)lt536

(468

)NS

Size

(cm)

65plusmn28

74plusmn29

019

mdashmdash

mdash73plusmn28

78plusmn28

03574plusmn24

74plusmn32

NS

5ndash1087

(509

)5ndash1037

(481

)

Septations

with

inabscess

0103

001

mdash

Unilocular

mdashmdash

mdash9(153

)19

(271)

5(54)

11(282

)mdash

mdashmdash

mdashmdash

Multilocular

84(60

)13

(619

)

043

50(847

)51

(729

)87

(946

)28

(718

)

41(387

)20

(357

)NS

mdashmdash

Gas-fo

rmationin

abscess

13(93)

2(95)

049

52(897

)

64(914

)

0536

11(282

)6(154

)058

24(329

)5(135

)lt005

7(41

)4(52)

NS

Septalenhancem

ent

mdashmdash

mdash44

(746

)41

(586

)0056

mdashmdash

mdash30

(411)

6(162

)lt005

mdashmdash

mdashRim-enh

ancement

68(486

)12

(571)

023

20(339

)43

(614

)

000

4mdash

mdashmdash

28(384

)12

(324

)NS

mdashmdash

mdashPn

eumob

ilia

9(64)

0(00)

012

mdashmdash

mdash1(11)

5(128

)001

7(96)

3(81

)NS

mdashmdash

mdashTh

rombo

phlebitis

2(14)

1(48

)013

mdashmdash

mdash28

(304

)2(51

)lt001

mdashmdash

mdashmdash

mdashmdash

mdashTh

erewereno

data


nsof

right

andleftareno

tmentio

nedseparatelyin


ndardlowast


ofabscessinadditio

nto

thosementio

nedin

reference[1]


Table4Antibiotic

treatmentinpatie

ntsw

ithKlebsiella

pneumoniaeliver

abscessa

ndStreptococcusm

illeriliver

abscess

KLA

Streptococcusm

illeri

Hon

gKo

ng(38)

(119899=140)

Sing

apore(4)

(119899=109)

Taiwan

(62)

(119899=110)

Turkey

(61)(119899=85)

Hon

gKo

ng(38)

(119899=21)

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Extend

ed-spectrum

penicillinlowast

217

48(343

)mdash

mdashmdash

mdashmdash

4(47)

154

11(524

)First-andsecond

-generation

ceph

alospo

rinssect

217

30(214

)32plusmn13

24(220

)mdash

104(945

)mdash

mdash154

4(19

)

Third

-and

fourth-generation

ceph

alospo

rins998771

217

50(357

)32plusmn13

71(651

)mdash

4(36)

mdash5(59)

154

3(14

3)

Carbapenem

sandmdash

mdash32plusmn13

13(119

)

mdashmdash

mdash42

(494

)

mdashmdash

Aminoglycosid

es

mdashmdash

mdash1(09

)mdash

104(945

)mdash

2(24)

mdashmdash

Quino

lonelowastlowast

mdashmdash

mdashmdash

mdashmdash

mdash11(129

)mdash

mdashlowast


ticarcillin-cla



eand

ertapenemm

erop

enem

am

ikacinlowastlowast

ciprofl

oxacin



(a)


(b)


(c)











8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















Table1Con

tinued

Case

Age

Sex

Race

Und

erlyingdiseases

Symptom

Locatio

nof

medicaltherapy

Outcome

Reference

1358

MJapanese

Diabetesm

ellitus

Malaise

Rightlob

eMerop

enem

(1givq12h)for

6dayscefm

etazole(

2givQ8h

)oralcefcapenep

ivoxil(100

mgtid

)and

antib

iotic

treatmentfor

30days

Survived

[5]

1461

FJapanese

Diabetesm

ellitus

Feverchillsanda

slighth

eadache

NR

Merop

enem

(1giv

q8h)

+lin

ezolid

(600

mgiv

q12h

)changedto

ceftriaxone

(2gq12h

)for

20days

follo

wed

byoralceph

alexin

(250

mgq6

h)for3

1days

Survived

[5]

1543

MJapanese

Non

eRight

hypo

chon

driaca

ndepigastricpain

Rightlob

eMerop

enem

(1gd

ayiv)for

15days

+IV

insulin

mgdayandoralciprofl

oxacin

(400

mgday)

for

50days

Survived

[45]

NR

notreported






















7 Therapy








Table3Com

paris

onof

CTim

agingcharacteris

ticsb

etweenKL

Aandno

n-KL

Arepo

rted

from

Hon

gKo

ng(38)K

orea

(30)Singapo

re(41)Taiwan

(35)and

China

(1)

Parameters

Hon

gKo

ng(38)

(119899=161)

Korea(

30)(119899=129)

Sing

apore(41)(119899=131)

China(

1)(119899=110)

Taiwan

(35)

(119899=248)

KLA(14

0)Non

-KLA

(21)

Pvalue

KLA(59)

Non

-KLA

(70)

Pvalue

KLA(92)

Non

-KLA

(39)

Pvalue

KLA(73)

Non

-KLA

(37)

Pvalue

KLA(171)

Non

-KLA

(77)

Pvalue

Noof

abscess

001

lt005

Solitary(119899=1)

mdashmdash

mdashmdash

mdashmdash

73(793

)

22(564

)60

(822

)30

(811)

NS

125(731

)45

(584

)Multip

le(119899gt1)

mdashmdash

mdashmdash

mdashmdash

19(207

)17

(436

)13

(178

)

7(189

)NS

46(269

)32

(416

)

Locatio

n0312

001

NS

Right

97(693

)

15(714

)

042

41(695

)

49(700

)76

(826)

sect(615

)

sect47

(644

)24

(649

)lowastNS

128(749

)52

(675

)

Left

31(221

)4(19

1)

038

14(237

)16

(229

)sect

sect11(151

)5(167

)lowastNS

34(19

9)

19(247

)Bo

th12

(86)

2(95)

044

4(68)

5(71

)16

(174

)

15(385

)2(27)lowast

1(27

)lowastNS

9(52)

6(78

)lt572

(421

)lt536

(468

)NS

Size

(cm)

65plusmn28

74plusmn29

019

mdashmdash

mdash73plusmn28

78plusmn28

03574plusmn24

74plusmn32

NS

5ndash1087

(509

)5ndash1037

(481

)

Septations

with

inabscess

0103

001

mdash

Unilocular

mdashmdash

mdash9(153

)19

(271)

5(54)

11(282

)mdash

mdashmdash

mdashmdash

Multilocular

84(60

)13

(619

)

043

50(847

)51

(729

)87

(946

)28

(718

)

41(387

)20

(357

)NS

mdashmdash

Gas-fo

rmationin

abscess

13(93)

2(95)

049

52(897

)

64(914

)

0536

11(282

)6(154

)058

24(329

)5(135

)lt005

7(41

)4(52)

NS

Septalenhancem

ent

mdashmdash

mdash44

(746

)41

(586

)0056

mdashmdash

mdash30

(411)

6(162

)lt005

mdashmdash

mdashRim-enh

ancement

68(486

)12

(571)

023

20(339

)43

(614

)

000

4mdash

mdashmdash

28(384

)12

(324

)NS

mdashmdash

mdashPn

eumob

ilia

9(64)

0(00)

012

mdashmdash

mdash1(11)

5(128

)001

7(96)

3(81

)NS

mdashmdash

mdashTh

rombo

phlebitis

2(14)

1(48

)013

mdashmdash

mdash28

(304

)2(51

)lt001

mdashmdash

mdashmdash

mdashmdash

mdashTh

erewereno

data


nsof

right

andleftareno

tmentio

nedseparatelyin


ndardlowast


ofabscessinadditio

nto

thosementio

nedin

reference[1]


Table4Antibiotic

treatmentinpatie

ntsw

ithKlebsiella

pneumoniaeliver

abscessa

ndStreptococcusm

illeriliver

abscess

KLA

Streptococcusm

illeri

Hon

gKo

ng(38)

(119899=140)

Sing

apore(4)

(119899=109)

Taiwan

(62)

(119899=110)

Turkey

(61)(119899=85)

Hon

gKo

ng(38)

(119899=21)

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Extend

ed-spectrum

penicillinlowast

217

48(343

)mdash

mdashmdash

mdashmdash

4(47)

154

11(524

)First-andsecond

-generation

ceph

alospo

rinssect

217

30(214

)32plusmn13

24(220

)mdash

104(945

)mdash

mdash154

4(19

)

Third

-and

fourth-generation

ceph

alospo

rins998771

217

50(357

)32plusmn13

71(651

)mdash

4(36)

mdash5(59)

154

3(14

3)

Carbapenem

sandmdash

mdash32plusmn13

13(119

)

mdashmdash

mdash42

(494

)

mdashmdash

Aminoglycosid

es

mdashmdash

mdash1(09

)mdash

104(945

)mdash

2(24)

mdashmdash

Quino

lonelowastlowast

mdashmdash

mdashmdash

mdashmdash

mdash11(129

)mdash

mdashlowast


ticarcillin-cla



eand

ertapenemm

erop

enem

am

ikacinlowastlowast

ciprofl

oxacin



(a)


(b)


(c)











8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





































7 Therapy








Table3Com

paris

onof

CTim

agingcharacteris

ticsb

etweenKL

Aandno

n-KL

Arepo

rted

from

Hon

gKo

ng(38)K

orea

(30)Singapo

re(41)Taiwan

(35)and

China

(1)

Parameters

Hon

gKo

ng(38)

(119899=161)

Korea(

30)(119899=129)

Sing

apore(41)(119899=131)

China(

1)(119899=110)

Taiwan

(35)

(119899=248)

KLA(14

0)Non

-KLA

(21)

Pvalue

KLA(59)

Non

-KLA

(70)

Pvalue

KLA(92)

Non

-KLA

(39)

Pvalue

KLA(73)

Non

-KLA

(37)

Pvalue

KLA(171)

Non

-KLA

(77)

Pvalue

Noof

abscess

001

lt005

Solitary(119899=1)

mdashmdash

mdashmdash

mdashmdash

73(793

)

22(564

)60

(822

)30

(811)

NS

125(731

)45

(584

)Multip

le(119899gt1)

mdashmdash

mdashmdash

mdashmdash

19(207

)17

(436

)13

(178

)

7(189

)NS

46(269

)32

(416

)

Locatio

n0312

001

NS

Right

97(693

)

15(714

)

042

41(695

)

49(700

)76

(826)

sect(615

)

sect47

(644

)24

(649

)lowastNS

128(749

)52

(675

)

Left

31(221

)4(19

1)

038

14(237

)16

(229

)sect

sect11(151

)5(167

)lowastNS

34(19

9)

19(247

)Bo

th12

(86)

2(95)

044

4(68)

5(71

)16

(174

)

15(385

)2(27)lowast

1(27

)lowastNS

9(52)

6(78

)lt572

(421

)lt536

(468

)NS

Size

(cm)

65plusmn28

74plusmn29

019

mdashmdash

mdash73plusmn28

78plusmn28

03574plusmn24

74plusmn32

NS

5ndash1087

(509

)5ndash1037

(481

)

Septations

with

inabscess

0103

001

mdash

Unilocular

mdashmdash

mdash9(153

)19

(271)

5(54)

11(282

)mdash

mdashmdash

mdashmdash

Multilocular

84(60

)13

(619

)

043

50(847

)51

(729

)87

(946

)28

(718

)

41(387

)20

(357

)NS

mdashmdash

Gas-fo

rmationin

abscess

13(93)

2(95)

049

52(897

)

64(914

)

0536

11(282

)6(154

)058

24(329

)5(135

)lt005

7(41

)4(52)

NS

Septalenhancem

ent

mdashmdash

mdash44

(746

)41

(586

)0056

mdashmdash

mdash30

(411)

6(162

)lt005

mdashmdash

mdashRim-enh

ancement

68(486

)12

(571)

023

20(339

)43

(614

)

000

4mdash

mdashmdash

28(384

)12

(324

)NS

mdashmdash

mdashPn

eumob

ilia

9(64)

0(00)

012

mdashmdash

mdash1(11)

5(128

)001

7(96)

3(81

)NS

mdashmdash

mdashTh

rombo

phlebitis

2(14)

1(48

)013

mdashmdash

mdash28

(304

)2(51

)lt001

mdashmdash

mdashmdash

mdashmdash

mdashTh

erewereno

data


nsof

right

andleftareno

tmentio

nedseparatelyin


ndardlowast


ofabscessinadditio

nto

thosementio

nedin

reference[1]


Table4Antibiotic

treatmentinpatie

ntsw

ithKlebsiella

pneumoniaeliver

abscessa

ndStreptococcusm

illeriliver

abscess

KLA

Streptococcusm

illeri

Hon

gKo

ng(38)

(119899=140)

Sing

apore(4)

(119899=109)

Taiwan

(62)

(119899=110)

Turkey

(61)(119899=85)

Hon

gKo

ng(38)

(119899=21)

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Extend

ed-spectrum

penicillinlowast

217

48(343

)mdash

mdashmdash

mdashmdash

4(47)

154

11(524

)First-andsecond

-generation

ceph

alospo

rinssect

217

30(214

)32plusmn13

24(220

)mdash

104(945

)mdash

mdash154

4(19

)

Third

-and

fourth-generation

ceph

alospo

rins998771

217

50(357

)32plusmn13

71(651

)mdash

4(36)

mdash5(59)

154

3(14

3)

Carbapenem

sandmdash

mdash32plusmn13

13(119

)

mdashmdash

mdash42

(494

)

mdashmdash

Aminoglycosid

es

mdashmdash

mdash1(09

)mdash

104(945

)mdash

2(24)

mdashmdash

Quino

lonelowastlowast

mdashmdash

mdashmdash

mdashmdash

mdash11(129

)mdash

mdashlowast


ticarcillin-cla



eand

ertapenemm

erop

enem

am

ikacinlowastlowast

ciprofl

oxacin



(a)


(b)


(c)











8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















Table3Com

paris

onof

CTim

agingcharacteris

ticsb

etweenKL

Aandno

n-KL

Arepo

rted

from

Hon

gKo

ng(38)K

orea

(30)Singapo

re(41)Taiwan

(35)and

China

(1)

Parameters

Hon

gKo

ng(38)

(119899=161)

Korea(

30)(119899=129)

Sing

apore(41)(119899=131)

China(

1)(119899=110)

Taiwan

(35)

(119899=248)

KLA(14

0)Non

-KLA

(21)

Pvalue

KLA(59)

Non

-KLA

(70)

Pvalue

KLA(92)

Non

-KLA

(39)

Pvalue

KLA(73)

Non

-KLA

(37)

Pvalue

KLA(171)

Non

-KLA

(77)

Pvalue

Noof

abscess

001

lt005

Solitary(119899=1)

mdashmdash

mdashmdash

mdashmdash

73(793

)

22(564

)60

(822

)30

(811)

NS

125(731

)45

(584

)Multip

le(119899gt1)

mdashmdash

mdashmdash

mdashmdash

19(207

)17

(436

)13

(178

)

7(189

)NS

46(269

)32

(416

)

Locatio

n0312

001

NS

Right

97(693

)

15(714

)

042

41(695

)

49(700

)76

(826)

sect(615

)

sect47

(644

)24

(649

)lowastNS

128(749

)52

(675

)

Left

31(221

)4(19

1)

038

14(237

)16

(229

)sect

sect11(151

)5(167

)lowastNS

34(19

9)

19(247

)Bo

th12

(86)

2(95)

044

4(68)

5(71

)16

(174

)

15(385

)2(27)lowast

1(27

)lowastNS

9(52)

6(78

)lt572

(421

)lt536

(468

)NS

Size

(cm)

65plusmn28

74plusmn29

019

mdashmdash

mdash73plusmn28

78plusmn28

03574plusmn24

74plusmn32

NS

5ndash1087

(509

)5ndash1037

(481

)

Septations

with

inabscess

0103

001

mdash

Unilocular

mdashmdash

mdash9(153

)19

(271)

5(54)

11(282

)mdash

mdashmdash

mdashmdash

Multilocular

84(60

)13

(619

)

043

50(847

)51

(729

)87

(946

)28

(718

)

41(387

)20

(357

)NS

mdashmdash

Gas-fo

rmationin

abscess

13(93)

2(95)

049

52(897

)

64(914

)

0536

11(282

)6(154

)058

24(329

)5(135

)lt005

7(41

)4(52)

NS

Septalenhancem

ent

mdashmdash

mdash44

(746

)41

(586

)0056

mdashmdash

mdash30

(411)

6(162

)lt005

mdashmdash

mdashRim-enh

ancement

68(486

)12

(571)

023

20(339

)43

(614

)

000

4mdash

mdashmdash

28(384

)12

(324

)NS

mdashmdash

mdashPn

eumob

ilia

9(64)

0(00)

012

mdashmdash

mdash1(11)

5(128

)001

7(96)

3(81

)NS

mdashmdash

mdashTh

rombo

phlebitis

2(14)

1(48

)013

mdashmdash

mdash28

(304

)2(51

)lt001

mdashmdash

mdashmdash

mdashmdash

mdashTh

erewereno

data


nsof

right

andleftareno

tmentio

nedseparatelyin


ndardlowast


ofabscessinadditio

nto

thosementio

nedin

reference[1]


Table4Antibiotic

treatmentinpatie

ntsw

ithKlebsiella

pneumoniaeliver

abscessa

ndStreptococcusm

illeriliver

abscess

KLA

Streptococcusm

illeri

Hon

gKo

ng(38)

(119899=140)

Sing

apore(4)

(119899=109)

Taiwan

(62)

(119899=110)

Turkey

(61)(119899=85)

Hon

gKo

ng(38)

(119899=21)

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Extend

ed-spectrum

penicillinlowast

217

48(343

)mdash

mdashmdash

mdashmdash

4(47)

154

11(524

)First-andsecond

-generation

ceph

alospo

rinssect

217

30(214

)32plusmn13

24(220

)mdash

104(945

)mdash

mdash154

4(19

)

Third

-and

fourth-generation

ceph

alospo

rins998771

217

50(357

)32plusmn13

71(651

)mdash

4(36)

mdash5(59)

154

3(14

3)

Carbapenem

sandmdash

mdash32plusmn13

13(119

)

mdashmdash

mdash42

(494

)

mdashmdash

Aminoglycosid

es

mdashmdash

mdash1(09

)mdash

104(945

)mdash

2(24)

mdashmdash

Quino

lonelowastlowast

mdashmdash

mdashmdash

mdashmdash

mdash11(129

)mdash

mdashlowast


ticarcillin-cla



eand

ertapenemm

erop

enem

am

ikacinlowastlowast

ciprofl

oxacin



(a)


(b)


(c)











8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















Table4Antibiotic

treatmentinpatie

ntsw

ithKlebsiella

pneumoniaeliver

abscessa

ndStreptococcusm

illeriliver

abscess

KLA

Streptococcusm

illeri

Hon

gKo

ng(38)

(119899=140)

Sing

apore(4)

(119899=109)

Taiwan

(62)

(119899=110)

Turkey

(61)(119899=85)

Hon

gKo

ng(38)

(119899=21)

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Duration

(days)

Efficiency

Extend

ed-spectrum

penicillinlowast

217

48(343

)mdash

mdashmdash

mdashmdash

4(47)

154

11(524

)First-andsecond

-generation

ceph

alospo

rinssect

217

30(214

)32plusmn13

24(220

)mdash

104(945

)mdash

mdash154

4(19

)

Third

-and

fourth-generation

ceph

alospo

rins998771

217

50(357

)32plusmn13

71(651

)mdash

4(36)

mdash5(59)

154

3(14

3)

Carbapenem

sandmdash

mdash32plusmn13

13(119

)

mdashmdash

mdash42

(494

)

mdashmdash

Aminoglycosid

es

mdashmdash

mdash1(09

)mdash

104(945

)mdash

2(24)

mdashmdash

Quino

lonelowastlowast

mdashmdash

mdashmdash

mdashmdash

mdash11(129

)mdash

mdashlowast


ticarcillin-cla



eand

ertapenemm

erop

enem

am

ikacinlowastlowast

ciprofl

oxacin



(a)


(b)


(c)











8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















(a)


(b)


(c)











8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of




















8 Prognosis


9 Conclusion




Acknowledgments


References


















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















an increasing prominent disease of klebsiella pneumoniae liver

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