Multiloculated Klebsiella liver abscess successfully treated with early laparoscopic drainage after failed percutaneous drainage: a case report

Introduction

Klebsiella pneumoniae has been reported as an important cause of pyogenic liver abscess in East Asia; however, its incidence has increasingly been reported in Western countries as well (1). Klebsiella pneumoniae liver abscess is characterized by metastatic infection, and delays in treatment are associated with poor outcomes (2). Therefore, early initiation of appropriate antibiotic therapy and timely drainage are essential for successful management (3). However, large multiloculated liver abscesses are associated with a high risk of percutaneous drainage failure, highlighting the importance of selecting an appropriate drainage strategy (4).

The optimal drainage strategy for pyogenic liver abscess remains controversial. Previous studies have reported variable recommendations regarding when to perform percutaneous catheter drainage or surgical drainage, and which approach should be considered first-line therapy. In addition, among the pathogens causing liver abscess, Klebsiella pneumoniae is particularly notable for its invasive potential and risk of metastatic infection. Despite this, clear recommendations regarding the optimal drainage strategy specifically for Klebsiella pneumoniae liver abscess remain limited.

We report a case of multiloculated large Klebsiella pneumoniae liver abscess in which initial percutaneous drainage was insufficient but early laparoscopic drainage achieved effective source control before the development of metastatic infection. Through this case, we highlight the potential importance of early surgical drainage in selected patients with Klebsiella pneumoniae liver abscess. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0077/rc).

Case presentation

A 70-year-old man with a history of prediabetes and chronic kidney disease presented with a 2-week history of progressively worsening right upper quadrant abdominal pain. On presentation, vital signs were notable for tachycardia with a heart rate of 107 beats per minute, while temperature was 37 ℃, blood pressure 112/65 mmHg, respiratory rate 18 breaths per minute, and oxygen saturation 97% on room air. Physical examination revealed marked right upper quadrant tenderness and hepatic percussion tenderness. Laboratory testing demonstrated elevated neutrophil-predominant white blood cell count of 12.1×10⁹/L [normal (4.0–10.0)×10⁹/L], elevated alkaline phosphatase 227 U/L (normal 40–129 U/L), elevated gamma-glutamyl transferase 84 U/L (normal 8–61 U/L), and hemoglobin A1c 6.1% (normal range 4.0–5.6%). Lactate was 0.8 mmol/L (normal 0.5–2.0 mmol/L). Contrast-enhanced abdominal computed tomography (CT) revealed an 11-cm complex multiloculated mass in the right hepatic lobe with peripheral enhancement, suspected of a liver abscess (Figure 1). All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Contrast-enhanced abdominal CT revealed a complex 11-cm multiloculated mass in the right hepatic lobe. CT, computed tomography.

Intravenous ceftriaxone and metronidazole were immediately initiated. Following initial fluid resuscitation and antibiotic therapy, the patient’s vital signs stabilized; therefore, based on multidisciplinary discussion with the general surgery and interventional radiology teams, percutaneous drainage was selected as the initial management strategy. On hospital day 1, percutaneous drainage was performed by interventional radiology. A single 8-French pigtail catheter was placed in the right posterior liver segment, yielding a total of 200 mL of purulent fluid. Culture of the aspirated fluid grew Klebsiella pneumoniae, confirming the diagnosis of Klebsiella pneumoniae liver abscess. The isolate was susceptible to third-generation cephalosporins, fluoroquinolones, and carbapenems, with no evidence of extended-spectrum β-lactamase production. Evaluation for hypervirulent Klebsiella pneumoniae was not performed. Blood cultures remained negative. Despite antibiotic therapy and percutaneous drainage with adequate drain output, along with aggressive flushing, the patient continued to experience severe pain and persistent leukocytosis, and follow-up CT demonstrated a persistent hepatic abscess and fluid collection despite appropriate catheter placement confirmed on imaging (Figure 2). Given these findings, the surgical team was promptly consulted for further management. On hospital day 6, he subsequently underwent laparoscopic partial liver resection with fenestration performed to facilitate fenestration (unroofing) of the abscess cavity under intraoperative ultrasound guidance using a four-port technique. Intraoperatively, a fluid collection was identified at the superior dome of the liver with an overlying inflammatory rind, which was incised and drained; the overlying liver tissue was partially resected using an ultrasonic energy device (Harmonic scalpel) to unroof the underlying abscess cavity. Two 10-French Jackson-Pratt drains were placed, one over the superior dome of the liver and the other within the unroofed abscess cavity. Postoperative imaging demonstrated marked improvement of the hepatic abscess without additional drainable collections (Figure 3). The patient’s symptoms and leukocytosis subsequently improved. On hospital day 14, he was discharged home in stable condition with one right upper quadrant drain in place and oral ciprofloxacin and metronidazole therapy. The patient completed a total of 4 weeks of antibiotic therapy following drainage, and the drainage catheter was removed 1 week after discharge. At 1-month outpatient follow-up, he was clinically well, with good appetite, no abdominal pain, and no leukocytosis. At 2 months outpatient follow-up after discharge, there was no evidence of recurrence, and follow-up was subsequently discontinued. Follow-up CT was not performed, as pre-discharge imaging demonstrated significant improvement and the patient was clinically stable without evidence of recurrence.

Figure 2 Contrast-enhanced abdominal CT after percutaneous drainage demonstrating a slight decrease in the size of the multiloculated liver abscess in the right hepatic lobe, with a new large perihepatic fluid collection along the hepatic dome and right lobe with wall thickening. Interval placement of a drainage catheter into a loculated collection within the abscess in the right posterior liver segment is noted (arrow). CT, computed tomography.

Figure 3 Postoperative contrast-enhanced abdominal CT demonstrating decreased size of the right hepatic lobe abscess, with increased intralesional gas and reduced fluid component. CT, computed tomography.

Discussion

Klebsiella pneumoniae liver abscess is associated with hypervirulent phenotypes and increasing antimicrobial resistance, which contribute to treatment resistance and a higher recurrence rate (5). In particular, patients with risk factors such as advanced age, diabetes mellitus, or underlying liver disease are at increased risk of bacteremia and metastatic infections, which may lead to poor outcomes (6). Therefore, selecting an appropriate drainage strategy is particularly important to prevent treatment delay in patients with Klebsiella pneumoniae liver abscess. In the present case, the patient developed a Klebsiella pneumoniae liver abscess in the setting of advanced age and prediabetes. Early drainage allowed prompt source control and likely prevented metastatic complications.

Management of pyogenic liver abscess requires not only early administration of appropriate antibiotics but also careful assessment of the need for drainage (1). Percutaneous drainage is generally recommended for abscesses ≥5 cm, and failure of percutaneous drainage warrants consideration of surgical drainage (7). In our patient, prompt antibiotic therapy and percutaneous drainage were performed. However, persistent symptoms and elevated inflammatory markers suggested percutaneous drainage failure.

Multiloculation is a known predictor of percutaneous drainage failure because septations limit effective catheter drainage (4). Previous observational studies have shown that multiloculated pyogenic liver abscesses ≥3 cm are associated with a high percutaneous drainage failure rate of approximately 28%, supporting early laparoscopic intervention as a potential first-line option for large multiloculated abscesses (5). These findings are consistent with our case, in which percutaneous drainage was insufficient for source control. This case therefore highlights the potential role of laparoscopic drainage in large multiloculated abscesses.

Regarding the safety of laparoscopic surgery, a recent systematic review reported no mortality events among the included studies (8). Although it is more invasive than percutaneous drainage, this safety profile supports consideration of early laparoscopic drainage, particularly in patients with Klebsiella pneumoniae liver abscess, which carries a high risk of disseminated infection (6). Furthermore, laparoscopic drainage has been reported to be safer, more effective, and preferable compared with open surgical management when feasible (9).

In the United States hospitalist system, inpatient management of liver abscess is typically led by internal medicine physicians, with surgical teams involved as consultants. Communication delays between services can contribute to delays in procedural interventions (10,11). In our case, close communication with both interventional radiology and surgical teams allowed timely surgical drainage after percutaneous drainage failure, contributing to a favorable outcome. This multidisciplinary collaboration was particularly important given the invasive nature of Klebsiella pneumoniae infection.

Conclusions

This case underscores the importance of carefully evaluating morphology and causative organism of abscess when selecting a drainage strategy for pyogenic liver abscess. In patients with multiloculated Klebsiella pneumoniae liver abscess, clinicians should maintain a low threshold for considering early surgical drainage.

Acknowledgments

The abstract of this article was previously presented as an oral presentation at the American College of Physicians Hawaii Chapter Scientific Meeting on February 28, 2026.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0077/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0077/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0077/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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