
==== Front
BMC Gastroenterol
BMC Gastroenterol
BMC Gastroenterology
1471-230X
BioMed Central London

39227812
3391
10.1186/s12876-024-03391-9
Research
Prognostic risk factors for pyogenic liver abscess caused by Klebsiella pneumoniae
Lyu Yunxiao lvyunxiao1986@gmail.com

Wang Bin
grid.452237.5 0000 0004 1757 9098 Department of Hepatobiliary Surgery, Dongyang People’s Hospital, Affiliated Dongyang Hospital of Wenzhou Medical University, 60 West Wuning Road, Dongyang, Zhejiang 322100 P.R. China
3 9 2024
3 9 2024
2024
24 2989 1 2024
29 8 2024
© The Author(s) 2024
2024
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Background

Pyogenic liver abscess (PLA) caused by Klebsiella pneumoniae can vary in severity, and several risk factors for the development of organ dysfunction in PLA have been implicated. However, few studies to date have explored the most common risk factors for clinical severity.

Methods

We conducted a study on patients with PLA caused by Klebsiella pneumoniae between February 2013 and December 2022.Using logistic regression analysis, we sought to identify factors associated with positive blood culture, septic shock, and intensive care unit (ICU) admission.

Results

After included 200 patients, we found that an elevated procalcitonin (PCT) level (p = 0.03), higher glucose level (p = 0.03), and lower total cholesterol (TC) level (p = 0.01) were associated with a higher likelihood of positive blood bacteriological culture. Additionally, an increased PCT level (p = 0.02) and lower TC level (p < 0.01) were associated with an elevated risk of septic shock. Furthermore, a higher PCT level (p < 0.01) was associated with a higher probability of ICU admission.

Conclusion

In patients with PLA caused by Klebsiella pneumoniae, the PCT, glucose, and TC levels were found to be associated with positive blood culture, septic shock, and ICU admission.

Keywords

Pyogenic liver abscess
Klebsiella pneumoniae
Blood bacteriological culture
Septic shock
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pmcBackground

Pyogenic liver abscess (PLA) is a serious yet relatively uncommon infectious disease with a mortality rate ranging from 2.8 to 10.8% [1, 2]. Common types of bacteria in liver abscesses include Escherichia coli and Klebsiella pneumoniae [3]. During the past few decades, K. pneumoniae has become the most common pathogen in China and throughout the Asia-Pacific region [4, 5]. Patients with diabetes who develop a K. pneumoniae-induced liver abscess are more likely to develop invasive K. pneumoniae liver abscess syndrome, which is characterized by a PLA with infection in other sites as well (e.g., lung abscess, endophthalmitis, meningitis, necrotizing fasciitis) [6].

Some studies that focused on the risk factors for PLA have shown that advanced age, diabetes mellitus, liver cirrhosis, and malignancy may be associated with the severity of PLA [7, 8]. Additionally, several studies have shown that the C-reactive protein level, neutrophil-to-lymphocyte ratio, and fibrinogen level are associated with a higher risk of poor outcomes in patients with PLA [9, 10]. A recent report showed that the total cholesterol (TC) level on admission is an independent prognostic factor in patients with PLA [11]. Low plasma TC levels are associated with wider changes in cholesterol metabolism and its functional roles, and these appear to play a significant role in sepsis pathophysiology [12]. However, studies on these indicators in patients with liver abscesses caused by K. pneumoniae infection remain scarce. Therefore, we explored the risk factors for positive blood culture, septic shock, and intensive care unit (ICU) admission in these patients.

Methods

Patients admitted to a tertiary care hospital with an intensive care unit capacity of 20 beds were included in the study from February 2013 to December 2022. PLA caused by K. pneumoniae was diagnosed when the following criteria were met. (1) At least one of the following symptoms were present: fever, chills, right upper quadrant or epigastric pain, nausea, vomiting, or diarrhea. (2) Contrast-enhanced computed tomography and/or magnetic resonance imaging findings were compatible with a liver abscess. (3) Pus and/or blood bacteriological culture was positive for K. pneumoniae [13]. Patients who met the following criteria were excluded: (1) age of < 18 years; (2) diagnosis of a parasitic, fungal, or amoebic abscess or an abscess caused by a liver tumor; and (3) treatment in another hospital before admission.

The following information was collected from the patients’ medical records in the electronic data system of our hospital: demographic characteristics (age and sex), vital signs at admission, clinical symptoms, comorbidities, diagnosis, laboratory data, and current medical condition. The laboratory values were collected on the first day of hospital admission or within 24 h after the clinical diagnosis of PLA. All outcomes were assessed within 24 h of PLA diagnosis.

The treatment procedure for PLA in our hospital was implemented according to the published literature [14]. All patients received broad-spectrum antibiotics until pus or blood culture susceptibility test results were available. If the following symptoms appeared, acute blood bacteriological culture was performed: (1) chills and shivering, (2) body temperature of > 38.5 °C, or (3) manifestations of shock. When ultrasound or CT examination showed that the abscess was liquefied, puncture drainage or puncture aspiration was performed, and bacterial culture of pus was initiated. Our institution employs this comprehensive treatment strategy for patients with PLA. Septic shock was diagnosed in patients with sepsis who developed persistent hypotension requiring vasopressors to maintain the mean arterial pressure at ≥ 65 mmHg and who had a serum lactate level of > 2 mmol/L despite adequate volume resuscitation [15].

Statistical analysis

Continuous variables conforming to a normal distribution are presented as mean ± standard deviation and were compared using a t-test. Non-normally distributed variables are presented as median (interquartile range). Descriptive statistics were used to summarize the demographic and clinical variables, which are presented as mean ± standard error of the mean. We performed multivariate analyses of the statistically significant factors identified in the univariate analyses using a logistic regression model. To identify the predictive factors, variables with a p-value of < 0.1 in the univariate analysis were further examined by logistic regression in the multivariate analysis. All statistical analyses were performed using R software version 4.1.1 (R Foundation for Statistical Computing, Vienna, Austria). Statistical significance was considered at a p-value of < 0.05.

Results

Baseline characteristics

In total, 200 patients were enrolled in this study. The flow diagram of the study was showed in Fig. 1. The patients’ baseline characteristics are shown in Table 1. Their age ranged from 18 to 94 years (mean: 61.7 years), and they comprised 135 male and 65 female patients. Their temperature on admission was 38.8 ℃ and mean body mass index was 21.6 kg/m2. A total of 68 patients did not undergo percutaneous drainage or puncture, 72 patients underwent drainage, and 60 patients underwent puncture. Ninety patients had diabetes mellitus, and 20 patients had a malignant tumor. A total of 132 patients underwent a pus bacteriological culture, among whom 119 patients obtained positive results and 13 obtained negative results; 63 patients did not undergo a pus culture. Finally, 177 patients underwent a blood culture, among whom 42 had positive results and 135 had negative results. Considering the severity of PLA, 18 patients suffered septic shock, and 13 patients required ICU admission that showed in Table 2. Due to the limited ICU beds in our hospital, five shock patients could not be admitted to the ICU for treatment. These patients were treated in the general ward and eventually recovered.The data of microbiological data in this study showed that two bacteriological culture showed ESBL positive. The antibiotic resistance showed ampicillin-resistance in 11 patients (5.50%), ceftriaxone-resistance in three patients (1.50%), cefoperazone and sulbactam-resistance in one patient (0.50%) and levofloxacin-resistance in threepatients (1.50%). The pus and blood bacteriological culture in one patient showed carbapenem-resistance and recovered after the use of cefidine/avibadan (Table 3).

Fig. 1 Flow diagram of the study

Table 1 The characteristics of included patients

Characteristics	Values	
Age, y	61.7 (13.4)	
Male, n (%)	135 (67.5)	
Temperature on admission, ℃	38.8 (1.1)	
MAP, mmHg	92.6 (14.9)	
BMI, Kg/m²	21.6 (3.6)	
Procalcitonin (< 0.1) ng/L	13.9 (24.7)	
C-reactive protein (< 10) mg/L	160.5 (55.8)	
WBC, (3.95–9.5)×10⁹/L	12.9 (5.8)	
Neutrophil, (1.8–6.3)×10⁹/L	10.9 (5.5)	
Platelet, (125–350)×10⁹/L	196.5 (101.9)	
Total bilirubin, (< 21) µmol/L	20.8(17.9)	
Direct bilirubin, (< 7)µ mol/L	12.4 (14.6)	
Aspartate aminotransferase, (7–40) U/L	74.1 (135.2)	
Alanine aminotransferase, (13–35) U/L	72.6 (84.9)	
γ-GT, (7–45) U/L	164.3 (145.2)	
Albumin, (40–55) g/L	31.2 (5.6)	
Glucose, (9.9–6.1) mmol/L	8.9 (4.2)	
Creatinine, (41–81) umol/L	77.8 (81.3)	
BUN, (3.1–8.8) mmol/L	6.1 (3.8)	
Total cholesterol, (< 5.18) mmol/L	3.3 (0.9)	
Triglycerides, (< 1.7) mmol/L	1.5 (0.9)	
HDL, (1.29–1.55) mmol/L	0.7 (0.3)	
LDL, (< 3.4) mmol/L	1.9 (0.8)	
INR (0.8–1.25)	1.2 (0.2)	
D-dimmer, (< 0.5) ug/ml	3.8 (3.9)	
Length, mm	45 (4.6)	
Comorbidities		
Diabetes mellitus, n (%)	90.0(45)	
Malignant tumor, n (%)	20.0(10)	
Length of hospital stay, days	15.1 (8.9)	
Duration of use of antibiotics, days	10.3 (7.6)	
Note Values are presented as mean (± standard deviation) or number (percentage). BMI: body mass index, WBC: white blood cell count, γ-GT: gamma-glutamyl transferase, BUN: blood urea nitrogen, HDL: high-density lipoprotein, LDL: low-density lipoprotein, INR: international normalized ratio

Table 2 The characteristics of severity in PLA

Characteristics	Values	
Procedure of drainage		
 None, n (%)	68(34.0)	
 Percutaneous drainage, n (%)	72 (36.0)	
 Percutaneous puncture, n (%)	60 (30.0)	
Blood bacteriological culture		
 Positive, n (%)	42 (21.0)	
 Negative, n (%)	135(67.5)	
Pus bacteriological culture		
 Positive, n (%)	119 (59.5)	
 Negative, n (%)	13 (6.5)	
 Septic shock		
 Yes	18 (9.0)	
 No	182 (91.0)	
 ICU admission		
 Yes	13 (6.5)	
 No	187 (93.5)	
Note ICU, intensive care unit

Table 3 The microbiological and antimicrobial susceptibility characteristics of the included patients

Characteristics	Values	
ESBL		
 Positive, n (%)	2 (1.0)	
 Negative, n (%)	198 (99.0)	
Antibiotic resistance		
 Ampicillin	11 (5.5)	
 Ceftriaxone	3 (1.5)	
 Cefoperazone and Sulbactam	1 (0.5)	
 Levofloxacin	3 (1.5)	
 Carbapenem	1 (0.5)	
Note ESBL, extended-spectrum beta-lactamases

Factors associated with positive blood culture

In univariate analysis, significant predictors of positive blood culture included male, procalcitonin (PCT), glucose, blood urea nitrogen (BUN), TC and low-density lipoprotein (LDL) (Table 4). The multivariate analysis showed that a higher PCT level (OR: 1.019, 95%CI: 1.002–1.038; p = 0.026), higher glucose level (OR: 1.113, 95%CI: 1.013–1.227; p = 0.027), and lower TC level (OR: 0.362, 95%CI: 0.152–0.753; p = 0.011) were associated with a higher incidence of blood culture positivity (Table 4).

Table 4 Univariate and multivariate analysis for PLA patients with positive blood bacteriological culture

Variables	Univariate analysis	Multivariate analysis	
OR (95% CI)	p value	OR (95% CI)	p value	
Age	0.999 (0.974–1.025)	0.939			
Gender (male)	2.391 (1.082–5.881)	0.042	2.241 (0.853–6.531)	0.116	
DM	1.644 (0.831–3.289)	0.155			
Malignant tumor	1.714 (0.574–4.602)	0.302			
Procalcitonin	1.025 (1.013–1.038)	< 0.001	1.019 (1.002–1.038)	0.026	
C-reactive protein	1.002 (0.996–1.009)	0.428			
Total bilirubin	1.009 (0.991–1.026)	0.311			
Direct bilirubin	1.011 (0.989–1.033)	0.275			
Aspartate aminotransferase	1.001 (0.999–1.003)	0.311			
Alanine aminotransferase	1.002 (0.999–1.005)	0.294			
WBC	1.028 (0.97–1.087)	0.34			
PLT	0.997 (0.993-1.000)	0.086	0.999 (0.995–1.004)	0.873	
Albumin	0.942 (0.885–1.001)	0.0572	1.001 (0.916–1.091)	0.989	
Glucose	1.172 (1.083–1.274)	< 0.001	1.113 (1.013–1.227)	0.027	
Creatinine	1.000 (0.994–1.004)	0.839			
BUN	1.121 (1.029–1.236)	0.015	1.051 (0.9-1.164)	0.419	
Total cholesterol	0.463 (0.303–0.685)	< 0.001	0.362 (0.152–0.753)	0.011	
Triglycerides	1.394 (0.974–2.058)	0.071	1.374 (0.819–2.452)	0.247	
HDL	0.552 (0.181–1.566)	0.278			
LDL	0.731(0.259–0.851)	0.002	1.803 (0.65–5.494)	0.272	
INR	5.549 (0.989–45.342)	0.073	5.551 (0.097–11.39)	0.919	
D-Dimer	1.071 (0.99–1.155)	0.077	0.962 (0.857–1.068)	0.484	
Note OR, Odds Ratio, WBC: white blood cell count, γ-GT: gamma-glutamyl transferase, BUN: blood urea nitrogen, HDL: high-density lipoprotein, LDL: low-density lipoprotein, INR: international normalized ratio. P-values less than 0.05 were considered statistically significant

Factors associated with septic shock

In the univariate analysis, significant predictors of septic shock included PCT, glucose level, BUN, TC, high-density lipoprotein (HDL), LDL, INR, and D-dimerl (Table 5). In the multivariate analysis, a higher PCT level (OR: 1.031, 95%CI: 1.000-1.052); p = 0.015) and lower TC level (OR: 0.253, 95%CI: 0.091–0.704; p = 0.008) were associated with a higher incidence of septic shock (Table 5).

Table 5 Univariate and multivariate analysis for PLA patients with shock

Variables	Univariate analysis	Multivariate analysis	
OR (95% CI)	p value	OR (95% CI)	p value	
Age	1.011 (0.974–1.05)	0.568			
Gender (male)	1.764 (0.603–6.428)	0.334			
DM	1.247 (0.466–3.334)	0.655			
Malignant tumor	1.139(0.171–4.456)	0.869			
Procalcitonin	1.04 (1.03–1.06)	< 0.001	1.031 (1.000-1.052)	0.015	
C-reactive protein	1.007 (0.997–1.016)	0.179			
Total bilirubin	1.002 (0.971–1.025)	0.879			
Direct bilirubin	1.008 (0.974–1.035)	0.552			
Aspartate aminotransferase	1.001 (0.997–1.003)	0.488			
Alanine aminotransferase	0.998 (0.989–1.004)	0.758			
WBC	0.968 (0.879–1.052)	0.471			
PLT	0.995 (0.989-1.000)	0.113			
Albumin	0.891(0.813–0.972)	0.011	1.00 (0.991–1.013)	0.821	
Glucose	1.148 (1.034–1.275)	0.009	1.03 (0.891–1.291)	0.368	
Creatinine	0.992 (0.983–1.004)	0.858			
BUN	1.123 (1.018–1.253)	0.022	0.99 (0.792–1.231)	0.871	
Total cholesterol	0.206 (0.099–0.384)	< 0.001	0.253 (0.091–0.704)	0.008	
Triglycerides	1.432 (0.919–2.167)	0.079	1.37 (0.411–4.594)	0.628	
HDL	0.113 (0.016–0.633)	0.023	0.77 (0.021–37.472)	0.911	
LDL	0.195 (0.073–0.447)	< 0.001	1.38 (0.261–3.374)	0.630	
INR	1.415 (1.271–1.642)	< 0.001	1.09 (0.781–2.323)	0.122	
D-Dimer	1.161 (1.06–1.273)	0.001	1.09 (1.282–3.429)	0.291	
Note OR, Odds Ratio, WBC: white blood cell count, γ-GT: gamma-glutamyl transferase, BUN: blood urea nitrogen, HDL: high-density lipoprotein, LDL: low-density lipoprotein, INR: international normalized ratio. P-values less than 0.05 were considered statistically significant

Factors associated with ICU admission

In the univariate analysis, significant predictors of ICU included PCT, aspartate transaminase, glucose, BUN, triglyceride, and INR (Table 6). The multivariate analysis showed that a higher PCT level (OR: 1.018, 95%CI: 0.999–1.036; p = 0.001) was associated with a greater incidence of ICU admission (Table 6).

Table 6 Univariate and multivariate analysis for PLA patients with ICU admission

Variables	Univariate analysis	Multivariate analysis	
OR (95% CI)	p value	OR (95% CI)	p value	
Age	1.006 (0.965–1.052)	0.772			
Gender (male)	1.653 (0.485–7.568)	0.457			
DM	1.461 (0.468–4.699)	0.509			
Malignant tumor	1.707 (0.252–7.027)	0.508			
Procalcitonin	1.024(1.009–1.039)	0.021	1.018 (0.999–1.036)	0.001	
C-reactive protein	1.001 (0.991–1.012)	0.749			
Total bilirubin	0.994 (0.95–1.023)	0.744			
Direct bilirubin	1.002 (0.954–1.033)	0.934			
Aspartate aminotransferase	1.003 (1.000-1.005)	0.026	1.011 (1.001–1.023)	0.047	
Alanine aminotransferase	1.004 (0.998–1.007)	0.091	0.986 (0.965–1.27)	0.174	
WBC	0.986 (0.886–1.083)	0.794			
 PLT	0.996 (0.989–1.002)	0.306			
 Albumin	0.923 (0.834–1.02)	0.118			
 Glucose	1.149 (1.02–1.295)	0.019	1.103 (0.958–1.27)	0.164	
 Creatinine	1.001 (0.994–1.005)	0.487			
 BUN	1.153 (1.039–1.303)	0.017	1.119 (0.988–1.252)	0.232	
 Total cholesterol	0.983 (0.547–1.744)	0.954			
 Triglycerides	1.83 (1.192–3.026)	0.007	1.478 (0.881–2.669)	0.137	
 HDL	0.469 (0.067–2.622)	0.416			
 LDL	0.649 (0.283–1.395)	0.284			
 INR	1.883 (1.143–2.174)	0.044	1.909 (0.126–2.913)	0.641	
 D-Dimer	1.027 (0.882–1.15)	0.679			
Note OR, Odds Ratio, WBC: white blood cell count, γ-GT: gamma-glutamyl transferase, BUN: blood urea nitrogen, HDL: high-density lipoprotein, LDL: low-density lipoprotein, INR: international normalized ratio. P-values less than 0.05 were considered statistically significant

Discussion

In this retrospective study, we identified several laboratory indices associated with the severity of PLA caused by K. pneumoniae. Our study showed that higher PCT, higher glucose, and lower TC levels were associated with a higher incidence of positive blood bacteriological culture. A higher PCT level, lower TC level, and higher INR were associated with a higher incidence of septic shock. Finally, higher PCT and BUN levels were associated with a higher incidence of ICU admission.

The microbiologic etiology of PLA has recently changed and varies by geographic location [16]. During the past several decades, Escherichia coli is the most frequently isolated bacterium of PLA [7, 8]. Recent studies have shown an increasing prevalence of K. pneumoniae, especially in Southeast Asia [17, 18]. In our study, antibiotic resistance was showed in Table 3. Some studies have explored the relationship between certain clinical features and PLA. A recent study conducted by Li et al. [9] showed that a higher C-reactive protein-to-platelet ratio, neutrophil-to-lymphocyte and platelet ratio, and fibrinogen-to-platelet ratio were associated with a higher risk of poor outcomes. Additionally, Zhang et al. [19] found that the serum albumin-to-globulin ratio was associated with worse outcomes. Nonetheless, the bacterial etiology of liver abscesses in these studies varied and included E. coli, K. pneumoniae, and other microorganisms. Studies have shown that PLA caused by K. pneumoniae infection may be more severe, and some patients may even have multiple organ infections (e.g., intracranial infection or endophthalmitis) [20, 21]. However, few studies to date have focused on the factors related to the severity of PLA caused by K. pneumoniae infection.

Positive blood cultures are often considered an aspect of the severity of infectious disease, and they often increase patient mortality [22]. The serum PCT level has been shown to be positively correlated with the severity of several diseases [23, 24]. In our study, a higher PCT level was associated with a higher incidence of positive blood culture, septic shock, and ICU admission. These findings are consistent with those of previous studies showing that the PCT level can be used to predict bloodstream infection [25]. Our study also demonstrated that a higher glucose level was a risk factor for positive blood culture. Patients with diabetes are at greater risk of liver abscesses caused by K. pneumoniae infection than patients without diabetes [26]. Our study showed that the fasting blood glucose level is a risk factor for positive blood culture, suggesting that poorly controlled blood glucose may be more likely to cause K. pneumoniae-positive bloodstream infections. However, diabetes mellitus was not a risk factor for blood culture positivity in our study.

Our study showed that a lower TC level was associated with a higher incidence of positive blood culture and septic shock, similar to the findings reported by Feng et al. [11]. They showed that a low TC level on admission was an independent risk factor for PLA. Multiple studies have showed that a lower TC level is associated with higher mortality in patients with sepsis [27, 28]. The specific biological mechanism underlying this association is not fully understood. The reduction in the TC level caused by severe infection may be related to reduced intake; impaired intestinal absorption; or disrupted cholesterol transport, increased metabolism, and cholesterol consumption due to toxin removal [12, 28]. Although a previous study showed that the HDL and LDL levels are reduced in patients with sepsis [28], the HDL and LDL levels were not significantly correlated with PLA severity in the present study. Further research is needed to elucidate the specific mechanism for this.

Our study had several limitations. First, it was a retrospective study, which may have resulted in bias. Larger-sample studies are required in the future. Second, we only collected data within the first 24 h; however, some indices may change significantly in the early stage of the disease.

Conclusion

The PCT level, glucose level, TC level, INR, and BUN level were associated with a higher incidence of blood culture positivity, septic shock, and ICU admission in patients with PLA caused by K. pneumoniae.

Abbreviations

PLA Pyogenic liver abscess

ICU Intensive care unit

PCT Procalcitonin

OR Odds ratio

TC Total cholesterol

Acknowledgements

We thank Angela Morben, DVM, ELS, from Liwen Bianji (Edanz) (www.liwenbianji.cn), for editing the English text of a draft of this manuscript.

Author contributions

YX.L. and B.W. wrote the main manuscript text and YX.L. prepared tables and figure. All authors reviewed the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available because of hospital policy but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Dongyang People’s Hospital and followed the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients before data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Fang CT Lai SY Yi WC Hsueh PR Liu KL Chang SC Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess Clin Infect Dis 2007 45 3 284 93 10.1086/519262 17599305
Fang CT, Lai SY, Yi WC, Hsueh PR, Liu KL, Chang SC. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis. 2007;45(3):284–93.17599305 10.1086/519262
2. Shin SU Park CM Lee Y Kim EC Kim SJ Goo JM Clinical and radiological features of invasive Klebsiella pneumoniae liver abscess syndrome Acta Radiol (Stockholm Sweden: 1987) 2013 54 5 557 63
Shin SU, Park CM, Lee Y, Kim EC, Kim SJ, Goo JM. Clinical and radiological features of invasive Klebsiella pneumoniae liver abscess syndrome. Acta Radiol (Stockholm Sweden: 1987). 2013;54(5):557–63.
3. Jha AK Das A Chowdhury F Biswas MR Prasad SK Chattopadhyay S Clinicopathological study and management of liver abscess in a tertiary care center J Nat Sci Biol Med 2015 6 1 71 5 10.4103/0976-9668.149091 25810638
Jha AK, Das A, Chowdhury F, Biswas MR, Prasad SK, Chattopadhyay S. Clinicopathological study and management of liver abscess in a tertiary care center. J Nat Sci Biol Med. 2015;6(1):71–5.25810638 10.4103/0976-9668.149091
4. Zhu X Wang S Jacob R Fan Z Zhang F Ji G A 10-year retrospective analysis of clinical profiles, laboratory characteristics and management of pyogenic liver abscesses in a Chinese hospital Gut Liver 2011 5 2 221 7 10.5009/gnl.2011.5.2.221 21814605
Zhu X, Wang S, Jacob R, Fan Z, Zhang F, Ji G. A 10-year retrospective analysis of clinical profiles, laboratory characteristics and management of pyogenic liver abscesses in a Chinese hospital. Gut Liver. 2011;5(2):221–7.21814605 10.5009/gnl.2011.5.2.221
5. Li W Chen H Wu S Peng J A comparison of pyogenic liver abscess in patients with or without diabetes: a retrospective study of 246 cases BMC Gastroenterol 2018 18 1 144 10.1186/s12876-018-0875-y 30285638
Li W, Chen H, Wu S, Peng J. A comparison of pyogenic liver abscess in patients with or without diabetes: a retrospective study of 246 cases. BMC Gastroenterol. 2018;18(1):144.30285638 10.1186/s12876-018-0875-y
6. Siu LK Yeh KM Lin JC Fung CP Chang FY Klebsiella pneumoniae liver abscess: a new invasive syndrome Lancet Infect Dis 2012 12 11 881 7 10.1016/S1473-3099(12)70205-0 23099082
Siu LK, Yeh KM, Lin JC, Fung CP, Chang FY. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis. 2012;12(11):881–7.23099082 10.1016/S1473-3099(12)70205-0
7. Lee JH Jang YR Ahn SJ Choi SJ Kim HS A retrospective study of pyogenic liver abscess caused primarily by Klebsiella pneumoniae vs. non-klebsiella pneumoniae: CT and clinical differentiation Abdom Radiol (NY) 2020 45 9 2669 79 10.1007/s00261-019-02389-2 31894381
Lee JH, Jang YR, Ahn SJ, Choi SJ, Kim HS. A retrospective study of pyogenic liver abscess caused primarily by Klebsiella pneumoniae vs. non-klebsiella pneumoniae: CT and clinical differentiation. Abdom Radiol (NY). 2020;45(9):2669–79.31894381 10.1007/s00261-019-02389-2
8. Wang H Ren Y Chang Z Liu Z The increased recurrence rate of liver abscess caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae Eur J Clin Microbiol Infect Dis 2020 39 7 1315 20 10.1007/s10096-020-03848-1 32062726
Wang H, Ren Y, Chang Z, Liu Z. The increased recurrence rate of liver abscess caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae. Eur J Clin Microbiol Infect Dis. 2020;39(7):1315–20.32062726 10.1007/s10096-020-03848-1
9. Li S Yu S Qin J Peng M Qian J Zhou P Prognostic value of platelet count-related ratios on admission in patients with pyogenic liver abscess BMC Infect Dis 2022 22 1 636 10.1186/s12879-022-07613-x 35864446
Li S, Yu S, Qin J, Peng M, Qian J, Zhou P. Prognostic value of platelet count-related ratios on admission in patients with pyogenic liver abscess. BMC Infect Dis. 2022;22(1):636.35864446 10.1186/s12879-022-07613-x
10. Li Z Xiao Y Zhang L Application of procalcitonin, white blood cell count and neutrophil-to-lymphocyte ratio in the diagnosis of systemic lupus erythematosus with a bacterial infection Ann Palliat Med 2020 9 6 3870 6 10.21037/apm-20-1777 33183029
Li Z, Xiao Y, Zhang L. Application of procalcitonin, white blood cell count and neutrophil-to-lymphocyte ratio in the diagnosis of systemic lupus erythematosus with a bacterial infection. Ann Palliat Med. 2020;9(6):3870–6.33183029 10.21037/apm-20-1777
11. Feng T Zhang W Hou X Yuan H Cai J Jiang Z Hu P Yue M Li W Zhu C Clinical significance of dynamic variation of low cholesterol and its prognostic value in patients with pyogenic liver abscesses: a retrospective study BMC Infect Dis 2023 23 1 70 10.1186/s12879-023-08011-7 36747151
Feng T, Zhang W, Hou X, Yuan H, Cai J, Jiang Z, Hu P, Yue M, Li W, Zhu C, et al. Clinical significance of dynamic variation of low cholesterol and its prognostic value in patients with pyogenic liver abscesses: a retrospective study. BMC Infect Dis. 2023;23(1):70.36747151 10.1186/s12879-023-08011-7
12. Hofmaenner DA Kleyman A Press A Bauer M Singer M The many roles of cholesterol in Sepsis: a review Am J Respir Crit Care Med 2022 205 4 388 96 10.1164/rccm.202105-1197TR 34715007
Hofmaenner DA, Kleyman A, Press A, Bauer M, Singer M. The many roles of cholesterol in Sepsis: a review. Am J Respir Crit Care Med. 2022;205(4):388–96.34715007 10.1164/rccm.202105-1197TR
13. Foo NP Chen KT Lin HJ Guo HR Characteristics of pyogenic liver abscess patients with and without diabetes mellitus Am J Gastroenterol 2010 105 2 328 35 10.1038/ajg.2009.586 19826410
Foo NP, Chen KT, Lin HJ, Guo HR. Characteristics of pyogenic liver abscess patients with and without diabetes mellitus. Am J Gastroenterol. 2010;105(2):328–35.19826410 10.1038/ajg.2009.586
14. Lardière-Deguelte S Ragot E Amroun K Piardi T Dokmak S Bruno O Appere F Sibert A Hoeffel C Sommacale D Hepatic abscess: diagnosis and management J Visc Surg 2015 152 4 231 43 10.1016/j.jviscsurg.2015.01.013 25770745
Lardière-Deguelte S, Ragot E, Amroun K, Piardi T, Dokmak S, Bruno O, Appere F, Sibert A, Hoeffel C, Sommacale D, et al. Hepatic abscess: diagnosis and management. J Visc Surg. 2015;152(4):231–43.25770745 10.1016/j.jviscsurg.2015.01.013
15. Singer M Deutschman CS Seymour CW Shankar-Hari M Annane D Bauer M Bellomo R Bernard GR Chiche JD Coopersmith CM The Third International Consensus definitions for Sepsis and septic shock (Sepsis-3) JAMA 2016 315 8 801 10 10.1001/jama.2016.0287 26903338
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, et al. The Third International Consensus definitions for Sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–10.26903338 10.1001/jama.2016.0287
16. Liu Y Liu J Fu L Jiang C Peng S Demographics and clinical outcomes of culture-positive versus culture-negative Pyogenic Liver Abscess in an Asian Population Infect Drug Resist 2023 16 903 11 10.2147/IDR.S395428 36814829
Liu Y, Liu J, Fu L, Jiang C, Peng S. Demographics and clinical outcomes of culture-positive versus culture-negative Pyogenic Liver Abscess in an Asian Population. Infect Drug Resist. 2023;16:903–11.36814829 10.2147/IDR.S395428
17. Yin D Ji C Zhang S Wang J Lu Z Song X Jiang H Lau WY Liu L Clinical characteristics and management of 1572 patients with pyogenic liver abscess: a 12-year retrospective study Liver Int 2021 41 4 810 8 10.1111/liv.14760 33314531
Yin D, Ji C, Zhang S, Wang J, Lu Z, Song X, Jiang H, Lau WY, Liu L. Clinical characteristics and management of 1572 patients with pyogenic liver abscess: a 12-year retrospective study. Liver Int. 2021;41(4):810–8.33314531 10.1111/liv.14760
18. Kong H Yu F Zhang W Li X Clinical and microbiological characteristics of pyogenic liver abscess in a tertiary hospital in East China Med (Baltim) 2017 96 37 e8050 10.1097/MD.0000000000008050
Kong H, Yu F, Zhang W, Li X. Clinical and microbiological characteristics of pyogenic liver abscess in a tertiary hospital in East China. Med (Baltim). 2017;96(37):e8050.10.1097/MD.0000000000008050
19. Zhang J Wang T Fang Y Wang M Liu W Zhao J Wang B Wu Z Lv Y Wu R Clinical significance of serum Albumin/Globulin ratio in patients with Pyogenic Liver Abscess Front Surg 2021 8 677799 10.3389/fsurg.2021.677799 34917645
Zhang J, Wang T, Fang Y, Wang M, Liu W, Zhao J, Wang B, Wu Z, Lv Y, Wu R. Clinical significance of serum Albumin/Globulin ratio in patients with Pyogenic Liver Abscess. Front Surg. 2021;8:677799.34917645 10.3389/fsurg.2021.677799
20. Chang Y Chen JH Chen WL Chung JY Klebsiella pneumoniae invasive syndrome with liver abscess and purulent meningitis presenting as acute hemiplegia: a case report BMC Infect Dis 2023 23 1 397 10.1186/s12879-023-08383-w 37308846
Chang Y, Chen JH, Chen WL, Chung JY. Klebsiella pneumoniae invasive syndrome with liver abscess and purulent meningitis presenting as acute hemiplegia: a case report. BMC Infect Dis. 2023;23(1):397.37308846 10.1186/s12879-023-08383-w
21. Cardenas-Alvarez J, Balayla G, Triana A, Diaz Lankenau R, Franco-Paredes C, Henao-Martínez AF, Motoa G. Clinical spectrum and outcomes of cryptogenic Klebsiella pneumoniae liver abscess in the Americas: a scoping review. Pathogens 2023, 12(5).
22. Xu Q Liu C Wu Z Zhang S Chen Z Shi Y Gu S Demographics and prognosis of patients with pyogenic liver abscess due to Klebsiella pneumonia or other species Heliyon 2024 10 8 e29463 10.1016/j.heliyon.2024.e29463 38638973
Xu Q, Liu C, Wu Z, Zhang S, Chen Z, Shi Y, Gu S. Demographics and prognosis of patients with pyogenic liver abscess due to Klebsiella pneumonia or other species. Heliyon. 2024;10(8):e29463.38638973 10.1016/j.heliyon.2024.e29463
23. Li F Ye Z Zhu J Gu S Peng S Fang Y Hu L Xiong J Early Lactate/Albumin and Procalcitonin/Albumin ratios as predictors of 28-Day mortality in ICU-Admitted Sepsis patients: a retrospective cohort study Med Sci Monit 2023 29 e940654 10.12659/MSM.940654 37518978
Li F, Ye Z, Zhu J, Gu S, Peng S, Fang Y, Hu L, Xiong J. Early Lactate/Albumin and Procalcitonin/Albumin ratios as predictors of 28-Day mortality in ICU-Admitted Sepsis patients: a retrospective cohort study. Med Sci Monit. 2023;29:e940654.37518978 10.12659/MSM.940654
24. Sobczak J, Burzyńska M, Sikora A, Wysocka A, Karawani J, Sikora JP. Post-Traumatic Stress Response and Appendicitis in Children-Clinical Usefulness of Selected Biomarkers. Biomedicines 2023, 11(7).
25. Zhou T Ren Z Ma Y He L Liu J Tang J Zhang H Early identification of bloodstream infection in hemodialysis patients by machine learning Heliyon 2023 9 7 e18263 10.1016/j.heliyon.2023.e18263 37519767
Zhou T, Ren Z, Ma Y, He L, Liu J, Tang J, Zhang H. Early identification of bloodstream infection in hemodialysis patients by machine learning. Heliyon. 2023;9(7):e18263.37519767 10.1016/j.heliyon.2023.e18263
26. Wendt S Bačák M Petroff D Lippmann N Blank V Seehofer D Zimmermann L Lübbert C Karlas T Clinical management, pathogen spectrum and outcomes in patients with pyogenic liver abscess in a German tertiary-care hospital Sci Rep 2024 14 1 12972 10.1038/s41598-024-63819-w 38839980
Wendt S, Bačák M, Petroff D, Lippmann N, Blank V, Seehofer D, Zimmermann L, Lübbert C, Karlas T. Clinical management, pathogen spectrum and outcomes in patients with pyogenic liver abscess in a German tertiary-care hospital. Sci Rep. 2024;14(1):12972.38839980 10.1038/s41598-024-63819-w
27. Lee JGH Genga KR Pisitsak C Boyd JH Leung AKK Russell JA Walley KR Survival benefit of a low ratio of visceral to subcutaneous adipose tissue depends on LDL clearance versus production in sepsis Crit Care 2018 22 1 58 10.1186/s13054-018-1985-1 29510719
Lee JGH, Genga KR, Pisitsak C, Boyd JH, Leung AKK, Russell JA, Walley KR. Survival benefit of a low ratio of visceral to subcutaneous adipose tissue depends on LDL clearance versus production in sepsis. Crit Care. 2018;22(1):58.29510719 10.1186/s13054-018-1985-1
28. Cirstea M Walley KR Russell JA Brunham LR Genga KR Boyd JH Decreased high-density lipoprotein cholesterol level is an early prognostic marker for organ dysfunction and death in patients with suspected sepsis J Crit Care 2017 38 289 94 10.1016/j.jcrc.2016.11.041 28013095
Cirstea M, Walley KR, Russell JA, Brunham LR, Genga KR, Boyd JH. Decreased high-density lipoprotein cholesterol level is an early prognostic marker for organ dysfunction and death in patients with suspected sepsis. J Crit Care. 2017;38:289–94.28013095 10.1016/j.jcrc.2016.11.041
