Demographic and clinical characteristic of the total patient population
During the study period, a total of 584 patients diagnosed as pyogenic liver abscess were inclded. Table 1 shows the demographic characteristics and clinical features of the total patients received hospital treatment for PLA during the study period. 27 patients were excluded who did not complete the treatment. A total of 557 patients were included: 225 had DM and 332 had not DM (P=0.209). Of the total patients, 150 men (66.67%) in DM group and 204 men (61.45%) in the non-DM group. Between the DM and non-DM groups, the most relevant past medical history was hypertension (95 vs 95 patients, 42.22% vs 28.61%), hyperlipemia (3 vs 4 patients, 1.33% vs 1.20%), viral hepatitis (13 vs 21patients, 5.78% vs 6.33%), fatty liver (87 vs 97 patients, 38.67% vs 29.22%), biliary stone (60 vs 91 patients, 26.67% vs 27.41%), biliary inflammation (31 vs 45 patients, 13.78% vs 13.55%), respectively. The most common clinical symptoms were fever (203 vs 307, 90.22% vs 92.47%), chill (56 vs 72, 24.89% vs 21.69%), diarrhea (6 vs 12, 2.67% vs 3.61%), frail (41 vs 28, 18.22% vs 8.43%), abdominal distension (16 vs 18, 7.11% vs 5.42%), vomit (25vs 36, 11.11% vs 10.84%), respectively.
Table 1 Demographic and clinical characteristic of the total patient population
Variables
|
DM
|
non-DM
|
P value
|
Number
|
225
|
332
|
|
Age(median, IQR)
|
|
|
|
male, n (%)
|
150(66.67)
|
204(61.45)
|
0.209
|
Past medical history, n (%)
|
|
|
|
Hypertension
|
95(42.22)
|
95(28.61)
|
<0.001
|
Viral hepatitis
|
13(5.78)
|
21(6.33)
|
0.791
|
Fatty liver
|
87(38.67)
|
97(29.22)
|
0.02
|
Biliary stone
|
60(26.67)
|
91(27.41)
|
0.847
|
History of intra-abdominal surgery
|
18(8.00)
|
72(21.69)
|
<0.001
|
History of liver abscess
|
4(1.78)
|
6(1.81)
|
0.98
|
Hepatic cyst
|
18(8.00)
|
39(11.75)
|
0.152
|
Pleural effusion, n(%)
|
98(43.56)
|
128(38.55)
|
0.238
|
Peritoneal effusion, n(%)
|
53(23.56)
|
63(18.98)
|
0.192
|
Periorbital inflammation, (%)
|
5(0.0222)
|
0(0.00)
|
0.006
|
Smoking, (%)
|
28(12.44)
|
25(7.53)
|
0.052
|
Drinking, (%)
|
29(12.89)
|
26(7.83)
|
0.05
|
Clinical Symptoms, n (%)
|
|
|
|
Fever
|
203(90.22)
|
307(92.47)
|
0.349
|
Chill
|
56(24.89)
|
72(21.69)
|
0.378
|
Diarrhea
|
6(2.67)
|
12(3.61)
|
0.535
|
Frail
|
41(18.22)
|
28(8.43)
|
<0.001
|
Abdominal distension
|
16(7.11)
|
18(5.42)
|
0.414
|
Vomit
|
25(11.11)
|
36(10.84)
|
0.921
|
Weight loss
|
3(1.33)
|
1(0.30)
|
0.157
|
Anorexia
|
22(9.78)
|
16(4.82)
|
0.023
|
Jaundice
|
0
|
3(0.90)
|
0.153
|
Abdominal pain
|
63(28.00)
|
109(32.83)
|
0.226
|
Vasoactive agents, n (%)
|
9(4.00)
|
10(3.01)
|
0.528
|
Percutaneous transhepatic cholangial drainage, n (%)
|
165(73.33)
|
235(70.78)
|
0.512
|
Surgical resection, n(%)
|
11(4.89)
|
33(9.94)
|
0.03
|
hospital mortalities, n(%)
|
5(2.22%)
|
7(2.11%)
|
0.928
|
Laboratory results
Laboratory data recorded on admission was shown in Table 2A. There were significant differences in glucose metabolism between the diabetic and non-diabetic groups. In PLA with DM groups, inflammatory biomarkers were generally elevated, which included leukocyte and neutrophil count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT). Statistically significant differences between patients with or without DM were observed in neutrophilic granulocyte percentage (N%) (P = 0.034), total bilirubin (TB) (P = 0.022), conjugated bilirubin (CB) (P = 0.01), alkaline phosphatase (ALP) (P = 0.004), Albumin (P = 0.001), low density lipoprotein (P < 0.001), high density lipoprotein (P = 0.001), Apolipoprotein A (P = 0.013), blood sodium (P = 0.003) and chlorine (P = 0.032).
Table 2A Laboratory data for pyogenic liver abscess patients with DM and non-DM
|
DM
|
non-DM
|
P value
|
Number
|
225
|
332
|
|
White blood cell (×10^9/L)
|
11.02±5.84
|
10.77±5.40
|
0.618
|
N%
|
77.49502±12.84451
|
74.85109±15.10304
|
0.034
|
Hb(g/L)
|
112.24±21.2
|
115.52±19.052
|
0.061
|
PLT(×10^9/L)
|
256.753±136.8151
|
276.98±128.4282
|
0.081
|
Lymphocyte(%)
|
14.09051±10.31323
|
14.55654±9.785953
|
0.595
|
ESR(mm/H)
|
59.75±29.462
|
57.16±29.07
|
0.534
|
CRP (mg/L)
|
118.8±87.021
|
116.19±78.808
|
0.731
|
PCT (ng/mL)
|
9.51±20.926
|
7.99±20.726
|
0.446
|
Lactate (mmol/L)
|
2.4±1.784
|
2.18±2.539
|
0.599
|
TB (umol/L)
|
14.989±14.2793
|
19.163±27.1207
|
0.022
|
CB (umol/L)
|
8.61±10.699
|
12.53±23.582
|
0.01
|
ALT (U/L)
|
69.76±109.451
|
59.69±59.101
|
0.216
|
AST (U/L)
|
67.019±112.9154
|
48.742±63.9621
|
0.031
|
LDH (U/L)
|
245.63±91.569
|
258.07±125.923
|
0.284
|
ALP (U/L)
|
195.93±157.406
|
160.81±101.781
|
0.004
|
r-GT (U/L)
|
179.03±160.551
|
160.34±129.444
|
0.154
|
Albumin (g/L)
|
31.15±6.385
|
32.96±5.612
|
0.001
|
Glycometabolism
|
|
Blood glucose(mmol/L)
|
11.27±5.825
|
6.25±1.955
|
<0.001
|
Glycated hemoglobin(%)
|
9.72±2.939
|
5.99±1.422
|
<0.001
|
Glycated albumin(%)
|
27.49±8.649
|
16.14±3.467
|
<0.001
|
Lipometabolism
|
|
|
Total cholesterol(mmol/L)
|
3.3±3.087
|
3.36±0.98
|
0.819
|
Triglycerides(mmol/L)
|
1.43±0.694
|
1.22±0.56
|
0.006
|
Low density lipoprotein(mmol/L)
|
1.8±0.756
|
2.14±0.773
|
<0.001
|
Non-high-density lipoprotein cholesterol(mmol/L)
|
2.45±0.812
|
2.69±0.862
|
0.018
|
High-density lipoprotein(mmol/L)
|
0.56±0.269
|
0.67±0.287
|
0.001
|
Apolipoprotein A(g/L)
|
0.69±0.251
|
0.77±0.259
|
0.013
|
Apolipoprotein B(g/L)
|
0.76±0.408
|
0.75±0.225
|
0.899
|
Apolipoprotein E(mg/L)
|
42±14.296
|
43.79±17.075
|
0.364
|
Lipoprotein a(nmol/L)
|
155.34±220.611
|
143.27±183.942
|
0.632
|
Small dense low-density lipoprotein(mmol/L)
|
0.72±0.729
|
1±1.1
|
0.071
|
Na(mmol/L)
|
136.92±5.462
|
138.72±3.363
|
0.003
|
K(mmol/L)
|
4.01±0.562
|
3.91±0.58
|
0.154
|
Cl(mmol/L)
|
99.88±5.355
|
101.18±3.584
|
0.032
|
Creatinine (umol/L)
|
73.44±36.8
|
74.28±47.812
|
0.831
|
Blood urea nitroge(mmol/L)
|
7.97±21.87
|
5.47±10.056
|
0.08
|
GFR(ml/min/1.73m2)
|
96.59±35.085
|
94.6±18.178
|
0.481
|
Uric Acid(umol/L)
|
218.66±112.899
|
221.99±104.812
|
0.733
|
cTnT(ng/mL)
|
0.02±0.043
|
0.03±0.119
|
0.778
|
proBNP(pg/mL)
|
1276.85±3396.313
|
746.11±1634.103
|
0.082
|
CK(U/L)
|
368.23±2625.53
|
93.63±223.544
|
0.368
|
CKMB(U/L)
|
22.18±111.717
|
9.49±6.907
|
0.331
|
CKMM(U/L)
|
390.73±2694.599
|
89.91±227.572
|
0.357
|
There were no significant differences in percentage of leukocyte, N%, CRP and ESR between non-KPLA and KPLA with DM (Table 2B). However, significant differences were observed between KPLA and non-KPLA with DM patients in PCT (P=0.008), AST (P =0.026) and γ-GT (P = 0.032)
Table 2B Laboratory data between KPLA and non-KPLA with DM patients
Characterisctic
|
KP cases (n=141)
|
Non-KP cases (n=27)
|
P value
|
Number
|
141
|
27
|
|
WBC (×10^9/L)
|
12.01±7.00
|
10.73±4.00
|
0.149
|
N(%)
|
80.52±12.09
|
77.63±9.43
|
0.109
|
Hb(g/L)
|
113.98±18.42
|
109.53±25.61
|
0.205
|
PLT(×10^9/L)
|
249.56±139.81
|
261.29±145.89
|
0.614
|
Lymphocyte(%)
|
12.38±10.84
|
13.41±7.82
|
0.517
|
ESR(mm/H)
|
63.76±23.68
|
59.76±34.05
|
0.585
|
CRP(mg/L)
|
132.07±83.55
|
115.73±83.32
|
0.238
|
PCT(ng/mL)
|
13.75±25.55
|
5.55±9.80
|
0.008
|
Lactate(mmol/L)
|
2.55±1.54
|
2.27±2.49
|
0.647
|
TB(umol/L)
|
16.89±14.63
|
13.87±12.33
|
0.182
|
CB(umol/L)
|
9.62±10.13
|
8.00±9.25
|
0.315
|
ALT(U/L)
|
88.22±136.87
|
54.08±55.09
|
0.064
|
AST(U/L)
|
86.94±135.63
|
51.26±58.49
|
0.026
|
LDH(U/L)
|
255.05±112.37
|
250.16±78.45
|
0.801
|
ALP(U/L)
|
225.60±158.18
|
196.90±199.03
|
0.319
|
r-GT(U/L)
|
214.82±188.85
|
159.03±132.91
|
0.032
|
Albumin(g/L)
|
31.61±6.72
|
30.31±5.73
|
0.212
|
Na(mmol/L)
|
136.18±5.68
|
137.91±4.57
|
0.199
|
K(mmol/L)
|
3.98±0.52
|
4±0.72
|
0.926
|
Cl(mmol/L)
|
99.38±5.84
|
100.7±4.34
|
0.335
|
Iron metabolism
|
|
|
Serum iron(umol/L)
|
8.37±5.71
|
9.7±0.57
|
0.758
|
Unsaturated iron-binding capacity(umol/L)
|
18.24±7.55
|
21±7.94
|
0.593
|
Total iron binding capacity(umol/L)
|
21.94±6.24
|
25±9.17
|
0.512
|
Transferrin saturation(%)
|
31.4±19.92
|
16.11±21.04
|
0.273
|
Ferritin(ng/mL)
|
554.69±406.41
|
1343.80±249.84
|
0.001
|
Serum transferring receptor(mg/L)
|
0.95±0.51
|
0.95±0.51
|
NA
|
Creatinine (umol/L)
|
75.35±36.01
|
65.47±26.48
|
0.073
|
Blood urea nitrogen (mmol/L)
|
10.77±32.26
|
4.71±2.35
|
0.156
|
GFR (ml/min/1.73m2)
|
97.32±44.35
|
99.21±23.97
|
0.776
|
Uric Acid (umol/L)
|
225.73±121.68
|
208.53±114.23
|
0.391
|
cTnT (ng/mL)
|
0.02±0.05
|
0.01±0.02
|
0.24
|
proBNP (pg/mL)
|
1361.49±2832.31
|
813.95±707.65
|
0.127
|
Clinical characteristics and predictors of sepsis in patients with pyogenic liver abscess
Of the 549 patients with liver abscess, patients in the sepsis group were older and had a higher ratio of males. There were statistical difference in pulmonary infection, abdominal infection, pleural effusion and abdominal effusion between sepsis and non-sepsis group. In laboratory datas, WBC, N%, CRP, PCT and TNFα sepsis group was significantly higher than the non-sepsis group. Sepsis patients have a higher mortality rate (Table 3).
Table 3 Clinical characteristics of PLA patients with or without sepsis
|
Sepsis group
|
Non-Sepsis group
|
P
|
Number
|
113
|
436
|
|
Age
|
62.1±12.986
|
58.5±13.384
|
0.011
|
male, n (%)
|
81(71.7%)
|
269(61.7%)
|
0.049
|
Hypertension, n (%)
|
45(39.8%)
|
144(33%)
|
0.175
|
Diabetes mellitus, n (%)
|
75(66.4%)
|
285(65.4%)
|
0.841
|
Fatty liver, n (%)
|
34(30.1%)
|
150(34.4%)
|
0.386
|
History of intra-abdominal surgery
|
45(39.8%)
|
156(35.8%)
|
0.427
|
Lung infection, n (%)
|
36(31.9%)
|
85(19.5%)
|
0.005
|
Abdominal cavity infection, n (%)
|
11(9.7%)
|
18(4.1%)
|
0.018
|
Periorbital infection, n (%)
|
2(1.8%)
|
6(1.4%)
|
0.671
|
Pleural effusion, n (%)
|
66(58.4%)
|
170(39%)
|
<0.001
|
Abdominal cavity effusion, n (%)
|
24(21.2%)
|
69(15.8%)
|
0.172
|
WBC (×10^9/L)
|
10.9(7.2,15.9)
|
9.8(7.22,12.75)
|
0.009
|
N% (%)
|
86%(78%,90.3%)
|
77.2%(69.8,77.2)
|
<0.001
|
CRP (mg/L)
|
90(89,190.2)
|
90(53.23,166.65)
|
0.007
|
PCT (ng/mL)
|
6.14(1.27,33.78)
|
0.44(0.17,1.67)
|
<0.001
|
TNFα (pg/mL)
|
24.0(17.5,32.3)
|
11.5(9.23,17.3)
|
<0.001
|
mortality, n (%)
|
10(8.8%)
|
4(0.9%)
|
<0.001
|
Table 4 shows logistic regression analysis of factors associated with sepsis in the patients with PLA. Univariable analysis showed that clinical factors significantly associated with sepsis included age (OR: 1.021, 95% CI: 1.005-1.038), pleural effusion (OR: 2.197, 95% CI: 1.443-3.346), peritoneal effusion (OR: 2.504, 95% CI: 1.147-5.467), WBC (OR: 1.051, 95% CI: 1.021-1.094), CRP (OR: 1.003, 95% CI: 1.001-1.006), PCT (OR: 1.04, 95% CI: 1.027-1.054), PLT (OR: 0.98, 95% CI: 0.997-0.984), PT (OR: 1.247, 95% CI: 1.113-1.396), TB (OR: 1.165, 95% CI: 1.127-1.204). In the multivariate logistic regression analysis, we did not find independently factor associated with the development of sepsis in the PLA patients.
Table 4 Univariable and multivariable logistic regression analysis for factors predictive of Sofa≥2 in patients with pyogenic liver abscess
|
Univariate
|
OR(95% CI)
|
p Value
|
Age
|
1.021(1.005-1.038)
|
0.011
|
Hypertension
|
1.342(0.876-2.055)
|
0.176
|
Diabetes
|
1.046(0.675-1.619)
|
0.841
|
Fatty liver
|
0.821(0.524-1.284)
|
0.387
|
History of celiac disease
|
1.15(0.743-1.781)
|
0.531
|
Count of abscess
|
1.227(0.708-2.128)
|
0.465
|
Abscess location
|
|
0.924
|
Left lobe
|
0.975(0.583-1.631)
|
0.924
|
Both lobe or junction
|
0.872(0.444-1.715)
|
0.692
|
Abscess size (cm)
|
|
0.171
|
5-10
|
0.813(0.496-1.332)
|
0.411
|
>10
|
1.395(0.728-2.673)
|
0.316
|
Etiology
|
|
0.335
|
Klebsiella pneumoniae
|
1.365(0.824-2.259)
|
0.227
|
other
|
1.673(0.756-3.547)
|
0.211
|
Pleural effusion
|
2.197(1.443-3.346)
|
<0.001
|
Peritoneal effusion
|
2.504(1.147-5.467)
|
0.021
|
Abdominal pain
|
0.862(0.546-1.361)
|
0.524
|
Drainage
|
1.063(0.670-1.688)
|
0.795
|
Operation
|
0.734(0.346-1.555)
|
0.419
|
WBC (×10^9/L)
|
1.057(1.021-1.094)
|
0.002
|
CRP(mg/L)
|
1.003(1.001-1.006)
|
0.008
|
PCT(ng/mL)
|
1.04(1.027-1.054)
|
<0.001
|
PLT(×10^9/L)
|
0.98(0.977-0.984)
|
<0.001
|
PT (s)
|
1.247(1.113-1.396)
|
<0.001
|
TB (umol/L)
|
1.165(1.127-1.204)
|
<0.001
|
Creatinine (umol/L)
|
1.002(0.998-1.006)
|
0.335
|
BUN (mmol/L)
|
0.964(0.908-1.024)
|
0.234
|
cTnT (ng/mL)
|
4.934(0.456-53.401)
|
0.189
|
Microbiological characteristics in Diabetic patients with liver abscesses
Microbiological data were obtained from the blood and/or pus of the PLA patients. A total of 251 bacterial isolates were obtained from 414 patients. The bacterial species identified from blood and/or pus taken from liver abscesses are summarized in Table 6. Klebsiella pneumoniae was the most common bacterium in blood and pus cultures, being present in 46.12%. Of the 414 PLA patients in this cohort, 196 (46.12%) patients isolated Klebsiella pneumoniae. The others, in order, are escherichia coli(17, 4%), enterococcus (13, 3.06%), enterobacter (13, 3.06%), fungi (8.1.88%) and streptococcus(4, 0.90%), respectively.
Table 5 Composition of pathogens in PLA patients
Pathogen
|
Number
|
Percentage
|
negative
|
163
|
38.35%
|
klebsiella pneumoniae
|
196
|
46.12%
|
escherichia coli
|
17
|
4.00%
|
enterococcus
|
13
|
3.06%
|
enterobacterium
|
13
|
3.06%
|
fungi
|
8
|
1.88%
|
streptococcus
|
4
|
0.90%
|
As the technology matures, next-generation sequencing(NGS)had also been used in PLA patients in recent years. We analyzed 27 plasma/pus samples from PLA patients by NGS. The sensitivity of NGS was 75% in plasma and 95.42% in pus, which was obviously higher than the traditional bacterial culture(Table 6.
Table 6 Comparation the sensitivity of NGS with traditional bacterial culture
|
|
pus culture
|
total
|
P
|
positive
|
negative
|
pus NGS
|
positive
|
16
|
9
|
25
|
|
negative
|
1
|
0
|
1
|
total
|
|
17
|
9
|
26
|
sensitivity
|
96.42%
|
62.96%
|
|
0.021
|
|
|
|
|
|
|
|
|
blood culture
|
total
|
P
|
positive
|
negative
|
|
|
blood NGS
|
positive
|
3
|
20
|
23
|
|
negative
|
1
|
3
|
4
|
total
|
|
4
|
23
|
27
|
sensitivity
|
75.00%
|
16.67%
|
|
<0.001
|
|
|
|
|
|
|
|
|
blood NGS
|
total
|
P
|
positive
|
negative
|
pus NGS
|
positive
|
16
|
7
|
23
|
|
|
negative
|
0
|
1
|
1
|
total
|
|
16
|
8
|
24
|
0.016
|