Infection (2014) 42:595–596 DOI 10.1007/s15010-014-0617-1
CORRESPONDENCE
Emergence of Klebsiella pneumoniae liver abscesses in South-western Sydney R. Chavada • J. Ng • M. Maley • J. Descallar
Received: 5 December 2013 / Accepted: 18 March 2014 / Published online: 25 March 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Klebsiella pneumoniae liver abscess (KPLA) with metastatic infection has been recognised as an emerging infectious disease since being described originally from Taiwan (where it accounts for up to 78.5 % of all liver abscesses), subsequently from other Asian countries and, more recently, from non-Asian countries [1, 2]. The risk of metastatic infection with KPLA has been linked to APACHE II scores C20 and septic shock [1]. In non-Asian countries, KPLA syndrome cases have arisen predominantly in patients of Asian ethnicity [3, 4]. South-western Sydney is ethnically diverse, with 28 % of the total population and 12 % of regional hospital admissions being of Asian ethnicity (Australian Bureau of Statistics census data 2011; Clinical Information Department Statistics). We retrospectively reviewed patient files for this KPLA syndrome to determine their age, gender, ethnicity, travel history as recorded in formal infectious disease consultation, contact history, presenting features, APACHE II scores, diabetic status, baseline investigations, management and outcomes by the time of discharge. Data were analysed using SAS version 5.1 for Windows (Cary, NC, USA) and study approval was granted by the South
Part of this study was presented in a poster format at the 22nd European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), London, UK, March/April 2012. R. Chavada (&) J. Ng M. Maley Department of Infectious Diseases and Microbiology, Liverpool Hospital, SSWPS, Level 2, Corner Goulburn Street, Liverpool, NSW 2170, Australia e-mail: [email protected] J. Descallar Ingham Institute of Medical Research, Liverpool, NSW 2170, Australia
Western Sydney Local Health District (SWSLHD) ethics committee (QA2010/015). From 01/01/2001 to 31/12/2010, 180 patients were identified with liver abscess using ICD-10 (International Classification of Diseases) admission codes from SWSLHD hospitals. After excluding cases without radiologically proven liver abscess, 21 cases of KPLA (12 % of all liver abscesses) were identified by cross-referencing microbiology computer records of Klebsiella pneumoniae (KP) isolates in blood cultures or liver aspirates over the same period. This represents the largest study to date of KPLA in Australia. In two Sydney-based, 10-year reviews of liver abscess in general, one study had only 11 KPLA patients, whereas the other study documented 13 KP microbiological isolates without specifying the number of patients with KPLA [5, 6]. Of our 21 cases, 5 patients (24 %) developed metastatic infection (see Table 1), which is comparable to rates of 20–28 % in other KPLA case series from non-Asian countries [2, 4, 7]. There was a single death in the non-metastatic KPLA group, giving a 5 % mortality rate, which is at the lower end of the reported range varying from 4 to 10 % [2, 7]. Of this case series, 71 % (15 patients) were of Asian ethnicity, which is higher than the baseline of 28 %, supporting an association with KPLA, as has been found with other studies from non-Asian countries [3, 4, 7]. This association could be due to genetic susceptibility or KP being more frequent in the local microbiota. Using a significance threshold of P B 0.05, diabetes mellitus, high APACHE II score and septic shock were not significantly associated with metastatic disease, possibly because of the small patient numbers. However, large abscess size, intra-abscess gas formation and history of Asian travel were significantly associated with metastatic infection. Speculatively, the former two factors correlate with high organism burden and,
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Table 1 Clinical associations with and without metastatic infection Variable
Metastatic KPLA (n = 5)
Non-metastatic KPLA (n = 16)
P value
Age (years)
46.8 ± 12.3
58.8 ± 13.6
0.09
Male gender
2
13
0.11
Asian ethnicity
4
11
1.00
Travel in Asia (last 3 months)
3
0
0.008
Abscess diameter (cm)
8.0 ± 0.5
4.9 ± 2.2
0.001
Intra-abscess gas formation
2
0
0.047
Diabetes mellitus
1
6
0.62
Septic shock
3
3
0.11
APACHE II score
12.8 ± 1.5
11.9 ± 1.1
0.159
Table 2 Patients with metastatic infection
3–9 %, while metastatic meningitis has an incidence of 1–10 % in large KPLA studies. A limitation of this study is that patients with KPLA who were not cultured or were culture-negative were omitted. Only 14 of 21 patients (67 %) in this series underwent percutaneous drainage for liver abscess and it is unknown how many more patients would have been diagnosed with KPLA if more liver abscesses had been aspirated. As this study is retrospective, follow-up was only until discharge and data collection could not be standardised. For instance, only 10 patients (47 %) had formal fundoscopy to diagnose metastatic endophthalmitis and travel/contact history for travellers from Asia was only available in 16/21 (77 %) patients. As a purely descriptive study, there were no controls and because Australian KPLA is uncommon, patient numbers are low, despite the 10-year study period. The strength of this study is that it is one of the larger studies on KPLA from a non-Asian country and the largest case series from Australia to date. In conclusion, this study adds to the limited available data on KPLA from non-Asian countries and demonstrates that travel to an Asian country within 3 months is associated with metastatic infection in KPLA from a non-Asian setting. Further research is needed in order to confirm this finding and to explore whether there is any association between KPLA and contact with travellers from Asia.
Patient
Recent travel (3 months)
Overseas contact (3 months)
Clinical sites of infection
Source of Klebsiella pneumoniae isolates
1
Nil
Vietnam
Septic arthritis
Blood, liver aspirate, joint fluid (knee)
2
Vietnam
Nil
Peritonitis
Blood, liver aspirate, peritoneal fluid
Conflict of interest None (for any of the authors). No internal or external funding was received for this study.
Pneumonia, peritonitis
Blood, liver aspirate, peritoneal fluid
References
3
Nil
Vietnam
4
Sri Lanka
Nil
Pelvic abscess
Blood, liver aspirate, pelvic fluid
5
Malaysia
Nil
Septic arthritis, epidural abscess, osteomyelitis
Blood
hence, likelihood of disseminated infection. Recent travel in Asia has not been previously examined for metastatic infection in other non-Asian based studies [4, 7]. Nonetheless, travel to Asia was noted in all four cases of KPLA previously published from Australia [3]. Interestingly, in our two patients with metastatic infection who lacked a recent travel history, contact with overseas travellers from Asia (see Table 2) was noted. Metastatic endophthalmitis and meningitis were not diagnosed in this case series. This could reflect the small study size or undiagnosed cases given its retrospective nature, since metastatic endophthalmitis has an incidence of
123
1. Lee SS, Chen YS, Tsai HC, Wann SR, Lin HH, Huang CK, et al. Predictors of septic metastatic infection and mortality among patients with Klebsiella pneumoniae liver abscess. Clin Infect Dis. 2008;47:642–50. 2. Siu LK, Yeh KM, Lin JC, Fung CP, Chang FY. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis. 2012;12:881–7. 3. Anstey JR, Fazio TN, Gordon DL, Hogg G, Jenney AW, Maiwald M, et al. Community-acquired Klebsiella pneumoniae liver abscesses—an ‘‘emerging disease’’ in Australia. Med J Aust. 2010;193:543–5. 4. Pastagia M, Arumugam V. Klebsiella pneumoniae liver abscesses in a public hospital in Queens, New York. Travel Med Infect Dis. 2008;6:228–33. 5. Pang TC, Fung T, Samra J, Hugh TJ, Smith RC. Pyogenic liver abscess: an audit of 10 years’ experience. World J Gastroenterol. 2011;17:1622–30. 6. Barakate MS, Stephen MS, Waugh RC, Gallagher PJ, Solomon MJ, Storey DW, et al. Pyogenic liver abscess: a review of 10 years’ experience in management. Aust N Z J Surg. 1999;69:205–9. 7. Moore R, O’Shea D, Geoghegan T, Mallon PW, Sheehan G. Community-acquired Klebsiella pneumoniae liver abscess: an emerging infection in Ireland and Europe. Infection. 2013;41:681–6.
CORRESPONDENCE
Emergence of Klebsiella pneumoniae liver abscesses in South-western Sydney R. Chavada • J. Ng • M. Maley • J. Descallar
Received: 5 December 2013 / Accepted: 18 March 2014 / Published online: 25 March 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Klebsiella pneumoniae liver abscess (KPLA) with metastatic infection has been recognised as an emerging infectious disease since being described originally from Taiwan (where it accounts for up to 78.5 % of all liver abscesses), subsequently from other Asian countries and, more recently, from non-Asian countries [1, 2]. The risk of metastatic infection with KPLA has been linked to APACHE II scores C20 and septic shock [1]. In non-Asian countries, KPLA syndrome cases have arisen predominantly in patients of Asian ethnicity [3, 4]. South-western Sydney is ethnically diverse, with 28 % of the total population and 12 % of regional hospital admissions being of Asian ethnicity (Australian Bureau of Statistics census data 2011; Clinical Information Department Statistics). We retrospectively reviewed patient files for this KPLA syndrome to determine their age, gender, ethnicity, travel history as recorded in formal infectious disease consultation, contact history, presenting features, APACHE II scores, diabetic status, baseline investigations, management and outcomes by the time of discharge. Data were analysed using SAS version 5.1 for Windows (Cary, NC, USA) and study approval was granted by the South
Part of this study was presented in a poster format at the 22nd European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), London, UK, March/April 2012. R. Chavada (&) J. Ng M. Maley Department of Infectious Diseases and Microbiology, Liverpool Hospital, SSWPS, Level 2, Corner Goulburn Street, Liverpool, NSW 2170, Australia e-mail: [email protected] J. Descallar Ingham Institute of Medical Research, Liverpool, NSW 2170, Australia
Western Sydney Local Health District (SWSLHD) ethics committee (QA2010/015). From 01/01/2001 to 31/12/2010, 180 patients were identified with liver abscess using ICD-10 (International Classification of Diseases) admission codes from SWSLHD hospitals. After excluding cases without radiologically proven liver abscess, 21 cases of KPLA (12 % of all liver abscesses) were identified by cross-referencing microbiology computer records of Klebsiella pneumoniae (KP) isolates in blood cultures or liver aspirates over the same period. This represents the largest study to date of KPLA in Australia. In two Sydney-based, 10-year reviews of liver abscess in general, one study had only 11 KPLA patients, whereas the other study documented 13 KP microbiological isolates without specifying the number of patients with KPLA [5, 6]. Of our 21 cases, 5 patients (24 %) developed metastatic infection (see Table 1), which is comparable to rates of 20–28 % in other KPLA case series from non-Asian countries [2, 4, 7]. There was a single death in the non-metastatic KPLA group, giving a 5 % mortality rate, which is at the lower end of the reported range varying from 4 to 10 % [2, 7]. Of this case series, 71 % (15 patients) were of Asian ethnicity, which is higher than the baseline of 28 %, supporting an association with KPLA, as has been found with other studies from non-Asian countries [3, 4, 7]. This association could be due to genetic susceptibility or KP being more frequent in the local microbiota. Using a significance threshold of P B 0.05, diabetes mellitus, high APACHE II score and septic shock were not significantly associated with metastatic disease, possibly because of the small patient numbers. However, large abscess size, intra-abscess gas formation and history of Asian travel were significantly associated with metastatic infection. Speculatively, the former two factors correlate with high organism burden and,
123
596
R. Chavada et al.
Table 1 Clinical associations with and without metastatic infection Variable
Metastatic KPLA (n = 5)
Non-metastatic KPLA (n = 16)
P value
Age (years)
46.8 ± 12.3
58.8 ± 13.6
0.09
Male gender
2
13
0.11
Asian ethnicity
4
11
1.00
Travel in Asia (last 3 months)
3
0
0.008
Abscess diameter (cm)
8.0 ± 0.5
4.9 ± 2.2
0.001
Intra-abscess gas formation
2
0
0.047
Diabetes mellitus
1
6
0.62
Septic shock
3
3
0.11
APACHE II score
12.8 ± 1.5
11.9 ± 1.1
0.159
Table 2 Patients with metastatic infection
3–9 %, while metastatic meningitis has an incidence of 1–10 % in large KPLA studies. A limitation of this study is that patients with KPLA who were not cultured or were culture-negative were omitted. Only 14 of 21 patients (67 %) in this series underwent percutaneous drainage for liver abscess and it is unknown how many more patients would have been diagnosed with KPLA if more liver abscesses had been aspirated. As this study is retrospective, follow-up was only until discharge and data collection could not be standardised. For instance, only 10 patients (47 %) had formal fundoscopy to diagnose metastatic endophthalmitis and travel/contact history for travellers from Asia was only available in 16/21 (77 %) patients. As a purely descriptive study, there were no controls and because Australian KPLA is uncommon, patient numbers are low, despite the 10-year study period. The strength of this study is that it is one of the larger studies on KPLA from a non-Asian country and the largest case series from Australia to date. In conclusion, this study adds to the limited available data on KPLA from non-Asian countries and demonstrates that travel to an Asian country within 3 months is associated with metastatic infection in KPLA from a non-Asian setting. Further research is needed in order to confirm this finding and to explore whether there is any association between KPLA and contact with travellers from Asia.
Patient
Recent travel (3 months)
Overseas contact (3 months)
Clinical sites of infection
Source of Klebsiella pneumoniae isolates
1
Nil
Vietnam
Septic arthritis
Blood, liver aspirate, joint fluid (knee)
2
Vietnam
Nil
Peritonitis
Blood, liver aspirate, peritoneal fluid
Conflict of interest None (for any of the authors). No internal or external funding was received for this study.
Pneumonia, peritonitis
Blood, liver aspirate, peritoneal fluid
References
3
Nil
Vietnam
4
Sri Lanka
Nil
Pelvic abscess
Blood, liver aspirate, pelvic fluid
5
Malaysia
Nil
Septic arthritis, epidural abscess, osteomyelitis
Blood
hence, likelihood of disseminated infection. Recent travel in Asia has not been previously examined for metastatic infection in other non-Asian based studies [4, 7]. Nonetheless, travel to Asia was noted in all four cases of KPLA previously published from Australia [3]. Interestingly, in our two patients with metastatic infection who lacked a recent travel history, contact with overseas travellers from Asia (see Table 2) was noted. Metastatic endophthalmitis and meningitis were not diagnosed in this case series. This could reflect the small study size or undiagnosed cases given its retrospective nature, since metastatic endophthalmitis has an incidence of
123
1. Lee SS, Chen YS, Tsai HC, Wann SR, Lin HH, Huang CK, et al. Predictors of septic metastatic infection and mortality among patients with Klebsiella pneumoniae liver abscess. Clin Infect Dis. 2008;47:642–50. 2. Siu LK, Yeh KM, Lin JC, Fung CP, Chang FY. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis. 2012;12:881–7. 3. Anstey JR, Fazio TN, Gordon DL, Hogg G, Jenney AW, Maiwald M, et al. Community-acquired Klebsiella pneumoniae liver abscesses—an ‘‘emerging disease’’ in Australia. Med J Aust. 2010;193:543–5. 4. Pastagia M, Arumugam V. Klebsiella pneumoniae liver abscesses in a public hospital in Queens, New York. Travel Med Infect Dis. 2008;6:228–33. 5. Pang TC, Fung T, Samra J, Hugh TJ, Smith RC. Pyogenic liver abscess: an audit of 10 years’ experience. World J Gastroenterol. 2011;17:1622–30. 6. Barakate MS, Stephen MS, Waugh RC, Gallagher PJ, Solomon MJ, Storey DW, et al. Pyogenic liver abscess: a review of 10 years’ experience in management. Aust N Z J Surg. 1999;69:205–9. 7. Moore R, O’Shea D, Geoghegan T, Mallon PW, Sheehan G. Community-acquired Klebsiella pneumoniae liver abscess: an emerging infection in Ireland and Europe. Infection. 2013;41:681–6.
