Community-Acquired resistant strain of Klebsiella pneumonia in an Elderly Hispanic patient in United States: causing Klebsiella-invasive Syndrome with Primary Liver Abscess and Antibiotic Resistance

Community-Acquired resistant strain of Klebsiella pneumonia in an Elderly Hispanic patient in United States: causing Klebsiella-invasive Syndrome with Primary Liver Abscess and Antibiotic Resistance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Community-Acquired resistant strain of Klebsiella pneumonia in an Elderly Hispanic patient in United States: causing Klebsiella-invasive Syndrome with Primary Liver Abscess and Antibiotic Resistance Imad Majeed, Roarke Swank, Naga Chadalapaka, Kenneth Schott Hannan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6450922/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Klebsiella pneumoniae (K. pneumoniae) commonly causes respiratory and urinary tract infections but can also lead to community-acquired liver abscesses, primarily in Asian populations. This condition is rare in the Americas and Europe. The emergence of Sulfhydryl Reagent Variable Extended-Spectrum Beta-Lactamase (SHV ESBL) strains complicates the management of these abscesses. A Hispanic female in her late 60s presented with bloody urine after three weeks of foul odor, dry cough, headache, and blurry vision. CT abdomen and pelvis showed a 1cm right-sided ureteral calculus and a 5cm focal liver density, later confirmed as a heterogeneous loculated abscess. A nephroureteral stent was placed. Ophthalmology ruled out endophthalmitis. Blood cultures showed K. pneumoniae, while urine cultures were negative. Cefepime was started based on sensitivity patterns. A CT-guided drain confirmed K. pneumoniae. qPCR and NGS revealed a positive SHV ESBL trait. Ertapenem was initiated due to the inability to specify the subtype. Persistent poor drainage prompted a drain change. Repeat imaging showed reduced abscess size. The patient was discharged on six weeks of intravenous ertapenem with weekly lab tests. This case emphasizes the importance of vigilance for community-acquired Klebsiella liver abscesses in patients with K. pneumoniae infections. Managing liver abscesses, especially those caused by SHV ESBL strains, is challenging due to the lack of specific diagnostic tools. Broad-spectrum antibiotics like carbapenems are cautiously used to prevent community resistance. Advancements in SHV ESBL studies are crucial for targeted therapy and appropriate antibiotic use. Klebsiella pneumonia Bacteremia Liver abscess Antibiotic resistance Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Klebsiella pneumoniae is a common pathogen that is known to cause liver abscess formation, classically described in Asian countries; [1,2,3,4] although rare, emerging cases in Europe and the Americas are increasingly being recognized and described. [5,6,7,8,9,10] Syndromes and clinical presentations vary; pyogenic liver abscess with bacteremia has been most frequently observed in Asian countries. For example, in Taiwan, one retrospective study found 78% of pyogenic liver abscesses were due to primary K. pneumoniae infection, [3] whereas in another study conducted in New York, USA, around 41% of cases were secondary to K. pneumoniae, with most of these cases occurring in Asian individuals. [10]Typical treatment includes percutaneous drainage with a 2nd or 3rd generation cephalosporin; however, pyogenic liver abscess syndrome due to K. pneumoniae still has an overarching mortality of 10% and a 15% rate of metastatic or invasive abscess syndrome. [3] We present a fascinating case of a Hispanic female in her late 60s with primary pyogenic liver abscess syndrome secondary to Klebsiella pneumoniae with concurrent bacteremia complicated by a Sulfhydryl Reagent Variable Extended-Spectrum Beta-Lactamase pattern resistance. Due to initial concern for Primary Invasive Community-Acquired Liver Syndrome, which has a shockingly high mortality rate, workup discovered a unique resistance pattern in this case that is, to our knowledge, the first described occurrence of its kind, highlighting the need for the development of additional precise sensitivity panels and optimization of antibiotic therapy. Case Presentation A Hispanic female in her late 60s presented to the emergency department with hematuria, foul-smelling urine, headaches, dry cough, and blurry vision for three weeks. The foul-smelling urine started 3 weeks from presentation, with headaches, dry cough, blurry vision, and hematuria developing one week from presentation. She also reported polyarthralgia. Past medical history significant for pre-diabetic status; cholecystectomy was performed nine years prior to presentation. Family and social histories were unremarkable. She did endorse an allergy to Penicillin that precipitates a rash. Physical exam demonstrated joint tenderness in the left knee to palpation, otherwise negative; CRP was 328.5 mg/L and ESR 125 mm/hr, which were significantly elevated. patient was meeting systemic inflammatory response syndrome (SIRS) criteria for sepsis, prompting an infectious disease workup; urinalysis was negative other than large hematuria, and chest x-ray suggested a mild case of atypical pneumonia. [Figure. 1] A CT without contrast demonstrated a 1-cm obstructing radiolucent stone in the proximal right ureter; Urology was consulted. Incidentally, a 5-cm hepatic lesion was detected. [Figure. 2a] Her bilirubin was elevated (2.1 mg/dl) and with a hepatocellular pattern of liver injury (AST: 76 U/L, ALT: 107 IU/L); MRI with and without contrast was ordered. She was started with empiric antibiotic regimen included Cefepime (IV 2g q8h) and Azithromycin (500mg q12h). Meanwhile, she was tested for other close differentials, causing liver abscesses with serologic tests for strongyloides and Entamoeba histolytica antibodies along with stool for ova and parasite, which came negative latter in the hospital course. On day two, the MRI identified the hepatic lesion as a 5-cm heterogeneous, loculated abscess; [Figure. 3a & b] at the same time, blood cultures obtained on the day of admission were positive for Klebsiella pneumoniae, with sensitivities pending initially. Based on new-onset blurry vision, headaches, Klebsiella bacteremia, polyarthralgia, and a hepatic abscess, clinical concern for Community-Acquired Klebsiella pneumoniae Invasive Syndrome complicated by Primary Liver Abscess, was established. Interventional radiology was consulted for drain placement and fluid culture collection, infectious disease recommended adding Microgen (Next-generation sequencing and Quantitative polymerase chain reaction) to precisely evaluate the etiology of the hepatic abscess, ophthalmology was consulted to rule out endophthalmitis, and a transesophageal echocardiogram was ordered to rule out infective endocarditis. Metronidazole (IV 500 mg q8hr) was initiated, and Azithromycin was discontinued due to low concern for atypical pneumonia (legionella and streptococcal pneumonia urine antigen were negative). Urology placed a ureteral stent to alleviate obstructive hydronephrosis; repeated urinalysis was also negative for urinary tract infection. Then, Ophthalmology ruled out endophthalmitis as the cause of the blurry vision, and the transesophageal echocardiogram was negative for vegetative disease, although moderate tricuspid regurgitation was identified. On day five, initial sensitivity culture results indicated Extended-Spectrum Beta-Lactamase positivity, prompting a switch to IV Cefepime 2g every 8 hour. Repeat blood cultures were negative at day five. On day seven, repeat CT demonstrated persistent abscess presence with no change in size. [Figure. 2b] This prompted a drain exchange on day nine for a larger gauge to encourage abscess drainage. At this time, Microgen test result was finalized, further indicating an unexpected finding of Sulfhydryl Reagent Variable Extended-Spectrum Beta-Lactamase positive Klebsiella pneumoniae. Finally, by day ten, Metronidazole and Cefepime were discontinued, and monotherapy with IV Ertapenem at 1g Q24H was initiated; six weeks of monotherapy with a midline placement on an outpatient basis was scheduled with a two-week follow-up appointment to remove the hepatic drain. At that time, repeat CT abdomen and pelvis revealed complete resolution of the abscess with no evidence of residual infection was achieved, [Figure. 5a & b] and the patient made a full recovery. The patient was followed up after two weeks. She reported feeling better and had no further issues or concerns. A CT imaging scan was repeated, which demonstrated the resolution of her previous collection. [Figure. 5a & b] Consequently, the drains were removed. Discussion Klebsiella pneumoniae is a Gram-negative, non-motile bacterium that frequently colonizes human mucosal surfaces, such as those in the gastrointestinal tract and oropharynx [11]. It can spread from these colonizing sites to other sterile tissues, causing infections such as urinary tract infections, pneumonia, and others in humans [12]. Reports have been published on the emergence and dissemination of hypervirulent (HV) or antibiotic-resistant strains of Klebsiella pneumoniae [13]. The factors most associated with its virulence include lipopolysaccharides, capsules, siderophores, and fimbriae (known as pili) [12]. Among these, the capsular component, synthesized by genes from the capsular polysaccharide synthesis (cps) locus, has been extensively studied for its role in virulence [11]. Seventy different capsular serotypes have been identified in the literature, with K1 and K2 serotypes most frequently associated with liver abscesses [14, 15]. In our patient, a mucoid strain of Klebsiella pneumoniae was detected in both blood culture and abscess aspirate, though it was not further classified into subtypes. Klebsiella pneumoniae has emerged as a significant cause of liver abscesses in the United States, with several reports published over the years. A review article identified 96 case reports in the United States, primarily involving patients of Asian descent. Only a few cases were reported in patients of Hispanic or Caucasian ethnicity, suggesting a possible genetic predisposition among individuals of Asian descent, which may explain the higher prevalence of Klebsiella -associated liver abscesses in this population [15]. The mechanism by which Klebsiella causes primary liver abscesses is not completely understood, but there is an observed association with diabetes and pre-diabetic conditions. Impaired glucose tolerance may contribute to the spread of infection by reducing neutrophil function, which is critical for breaking down the bacterial capsule [15]. Our patient had an HbA1c of 6.1 mmol/mol, placing her in the pre-diabetic range and increasing her risk of developing a primary liver abscess and bacteremia secondary to Klebsiella pneumoniae . K. pneumoniae is capable of infecting healthy individuals, particularly through its hypervirulent strains, and can lead to community-acquired infections such as pyogenic liver abscesses, meningitis, necrotizing fasciitis, endophthalmitis, and severe pneumonia [13]. Liver abscesses can be caused by bacterial, parasitic, or fungal pathogens. These pathogens can infect the liver through various routes, including the portal vein, biliary tree, hepatic artery, direct extension, or penetrating trauma [15]. In our case, the patient’s history of ureteral stones and diverticulosis likely contributed to the development of Klebsiella pneumoniae bacteremia and subsequent primary liver abscess. Most Klebsiella pneumoniae hospital-acquired infections originate from gastrointestinal tract colonization, which may extend to the urinary tract, respiratory tract, or bloodstream [16]. Klebsiella can also form biofilms on medical equipment (e.g., catheters and endotracheal tubes), leading to infections [17]. A review of the literature indicates that patients with Klebsiella pneumoniae -associated primary liver abscesses are typically treated with a combination of intravenous (IV) antibiotics and percutaneous liver drainage. Common antibiotic regimens include IV ceftriaxone and metronidazole, piperacillin-tazobactam, ceftriaxone alone, gatifloxacin, imipenem/levofloxacin, cefepime, ciprofloxacin/imipenem, or penicillin/gentamicin/metronidazole [15]. Our patient was initially treated with IV cefepime and metronidazole, along with percutaneous abscess drainage. However, due to the diverse resistant pattern of Klebsiella pneumoniae, it has developed resistance to beta-lactam antibiotics. [12]. A specimen from the abscess aspirate was sent for Microgen testing (next-generation sequencing), which revealed the presence of a resistant SHV beta-lactamase gene. The report also indicated resistance to fourth-generation cephalosporins. A timely decision was made to switch the patient’s antibiotic therapy to IV ertapenem, which prevented further complications. The SHV beta-lactamase gene confers resistance to various beta-lactam antibiotics. According to a review article, SHV genes are categorized into subgroups 2b, 2br, and 2be. Subgroup 2b is resistant to penicillin and early cephalosporins, subgroup 2br is resistant to clavulanic acid, and subgroup 2be is resistant to third- and fourth-generation cephalosporins [18]. We attempted to contact the Microgen (NGS and qPCR) testing facility to further classify the SHV-resistant gene into its specific subgroup. However, this was not performed, possibly due to unavailable testing methods. This report highlights the need for further subclassification of SHV beta-lactamase-resistant genes in Klebsiella pneumoniae . Early detection could help prevent complications and improve patient outcomes. Abbreviations SHV Sulfhydryl Reagent Variable ESBL Extended-Spectrum Beta-Lactamase CT Computed tomography MRI Magnetic resonance imaging Declarations Funding No funding was used. Competing interests The authors report no conflicts of interest concerning the material or methods used in this study or the findings specified in this paper. Ethics approval Not applicable. Consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient himself for the publication of this case report and any accompanying images. A copy of this written consent is available for review by the Editor-in-Chief of this journal. Data-availability Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Code Availability Not applicable. Authors' contributions IM: analyzed and interpreted patient data and procedures along with the writing of the manuscript. RS: interpretation and analysis of radiological imaging with the assistance of writing the manuscript and final review. NC: procedure with final review of the manuscript. KH: final review of the manuscript. All authors read and approved the final manuscript. Acknowledgments There are no acknowledgments to disclose. Authors and affiliations Department of Infectious Diseases, University of Louisville Hospital, Louisville, Kentucky, United States Imad Majeed Department of Internal Medicine, University of Louisville Hospital, Louisville, Kentucky, United States Roarke Swank Department of Internal Medicine, University of Louisville Hospital, Louisville, Kentucky, United States Naga Chadalapaka Department of infectious Diseases, University of Louisville Hospital, Louisville, Kentucky, United states Keneth Schott Hannan Corresponding author Correspondence to Imad Majeed. References Lee SS, Chen YS, Tsai HC, Wann SR, Lin HH, Huang CK, Liu YC. Predictors of septic metastatic infection and mortality among patients with Klebsiella pneumoniae liver abscess. Clinical infectious diseases. 2008 Sep 1;47(5):642-50. Wang JH, Liu YC, Lee SS, Yen MY, Chen YS, Wang JH, Wann SR, Lin HH. Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clinical Infectious Diseases. 1998 Jun 1;26(6):1434-8. Chang FY, Chou MY. Comparison of pyogenic liver abscesses caused by Klebsiella pneumoniae and non-K. pneumoniae pathogens. Journal of the Formosan Medical Association Taiwan yi zhi. 1995 May 1;94(5):232-7. Li J, Fu Y, Wang JY, Tu CT, Shen XZ, Li L, Jiang W. Early diagnosis and therapeutic choice of Klebsiella pneumoniae liver abscess. Frontiers of medicine in China. 2010 Sep;4:308-16. Pastagia M, Arumugam V. Klebsiella pneumoniae liver abscesses in a public hospital in Queens, New York. Travel medicine and infectious disease. 2008 Jul 1;6(4):228-33. McCabe R, Lambert L, Frazee B. Invasive Klebsiella pneumoniae infections, California, USA. Emerging infectious diseases. 2010 Sep;16(9):1490. Frazee BW, Hansen S, Lambert L. Invasive infection with hypermucoviscous Klebsiella pneumoniae: multiple cases presenting to a single emergency department in the United States. Annals of emergency medicine. 2009 May 1;53(5):639-42. Saccente M. Klebsiella pneumoniae liver abscess, endophthalmitis, and meningitis in a man with newly recognized diabetes mellitus. Clinical infectious diseases. 1999 Dec 1;29(6):1570-1. Nazir NT, Penfield JD, Hajjar V. Pyogenic liver abscess. Cleveland Clinic journal of medicine. 2010 Jul;77(7):426-7. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clinical infectious diseases. 2004 Dec 1;39(11):1654-9. Ko KS. The contribution of capsule polysaccharide genes to virulence of Klebsiella pneumoniae. Virulence. 2017 Jul 4;8(5):485-6. Paczosa MK, Mecsas J. Klebsiella pneumoniae: going on the offense with a strong defense. Microbiology and molecular biology reviews. 2016 Sep;80(3):629-61. Shon AS, Bajwa RP, Russo TA. Hypervirulent (hypermucoviscous) Klebsiella pneumoniae: a new and dangerous breed. Virulence. 2013 Feb 15;4(2):107-18. Pan YJ, Fang HC, Yang HC, Lin TL, Hsieh PF, Tsai FC, Keynan Y, Wang JT. Capsular polysaccharide synthesis regions in Klebsiella pneumoniae serotype K57 and a new capsular serotype. Journal of clinical microbiology. 2008 Jul;46(7):2231-40. Fazili T, Sharngoe C, Endy T, Kiska D, Javaid W, Polhemus M. Klebsiella pneumoniae liver abscess: an emerging disease. The American journal of the medical sciences. 2016 Mar 1;351(3):297-304. Podschun R, Ullmann U. Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenicity factors. Clinical microbiology reviews. 1998 Oct 1;11(4):589-603. Schroll C, Barken KB, Krogfelt KA, Struve C. Role of type 1 and type 3 fimbriae in Klebsiella pneumoniae biofilm formation. BMC microbiology. 2010 Dec;10:1-0. Liakopoulos A, Mevius D, Ceccarelli D. A review of SHV extended-spectrum β-lactamases: neglected yet ubiquitous. Frontiers in microbiology. 2016 Sep 5;7:1374. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6450922","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":443495094,"identity":"a37f9bc9-1d21-451f-b3dd-25b8efb8866e","order_by":0,"name":"Imad Majeed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBACNiCWbGwAMuQPH3zwASTCTqwWPgm2ZMMZIBFmImwCa5GT4DGT5gFxCWnhEzv88ObMHXZ5bNINxsY2v7bJ8zEzMH74mIPHYdJpxpYbzyQXs8kcSHyc23fbsI2ZgVly5jZ8WhLMJB+2MSe2MSQcNs7tuc0I1MLGzItXS/o3oJZ6oJbENmnLntv2RGjJMZPc2HY4sU0imU2a4cftRGK0FFvObDue2MZzjNmwt+F2chszYzNev8jPTt94s7etOnF+e//HBz/+3Lad39588MNHPFpQAWMbmGwgVj0I/CFF8SgYBaNgFIwUAABeOlB082vPiAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Louisville Hospital","correspondingAuthor":true,"prefix":"","firstName":"Imad","middleName":"","lastName":"Majeed","suffix":""},{"id":443495097,"identity":"7f9a779a-8759-45ef-a941-27ad55287619","order_by":1,"name":"Roarke Swank","email":"","orcid":"","institution":"University of Louisville Hospital","correspondingAuthor":false,"prefix":"","firstName":"Roarke","middleName":"","lastName":"Swank","suffix":""},{"id":443495099,"identity":"fdbc1b13-2394-4373-a99a-04aedbf87116","order_by":2,"name":"Naga Chadalapaka","email":"","orcid":"","institution":"University of Louisville Hospital","correspondingAuthor":false,"prefix":"","firstName":"Naga","middleName":"","lastName":"Chadalapaka","suffix":""},{"id":443495101,"identity":"d97ec7b5-0c77-4295-bc3b-2f87e27903f4","order_by":3,"name":"Kenneth Schott Hannan","email":"","orcid":"","institution":"University of Louisville Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kenneth","middleName":"Schott","lastName":"Hannan","suffix":""}],"badges":[],"createdAt":"2025-04-15 05:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6450922/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6450922/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80820158,"identity":"9b0d3754-ca9a-4f18-8b00-09c4e2953154","added_by":"auto","created_at":"2025-04-17 12:03:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":228661,"visible":true,"origin":"","legend":"\u003cp\u003eAnterior-posterior chest X-ray revealing mild diffuse interstitial prominence throughout the left greater than right lung, potentially indicated atypical pneumonia.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6450922/v1/866d68589794ee27e36174bc.png"},{"id":80820160,"identity":"89392028-0185-4dcd-aadc-48c3c1688860","added_by":"auto","created_at":"2025-04-17 12:03:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":254745,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Pre-procedural computed tomography (CT) abdomen demonstrated a 5 cm focal abnormality in the liver parenchyma, consistent with a liver abscess. (b) Post-procedural CT abdomen revealed the placement of a surgical drain within the liver abscess and its drainage.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6450922/v1/086846f6289d5718bd54c6ac.png"},{"id":80819637,"identity":"bbd9bff8-a98f-49a8-a0cd-34a76b6afc03","added_by":"auto","created_at":"2025-04-17 11:55:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":302485,"visible":true,"origin":"","legend":"\u003cp\u003e(a) An axial view of the T2-weighted image of MRI abdomen and pelvis demonstrates a multiloculated right hepatic lobe lesion accompanied by surrounding reactive hyperemia, suggesting Liver abscess. (b) An axial view of the T2-weighted image of MRI abdomen and pelvis reveals an obstructing calculus in the right mid ureter, leading to moderate upstream hydroureteronephrosis.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6450922/v1/f3299da1067dfe57a097dc8c.png"},{"id":80820159,"identity":"fca2f2ff-a374-44f2-9fb6-bfc4bc7b18bd","added_by":"auto","created_at":"2025-04-17 12:03:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":233411,"visible":true,"origin":"","legend":"\u003cp\u003eThis ultrasound image depicts the right upper quadrant of the abdomen, revealing a hypoechoic abscess in the right hepatic lobe. The abscess measures approximately 4.4 cm x 3.1 cm x 4.0 cm and contains a partially imaged pigtail drainage catheter. The central components of the abscess exhibit liquefaction.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6450922/v1/bd007ba1f0abb83826ea32a2.png"},{"id":80821172,"identity":"2e1ef248-d2b9-45ff-af93-78cd845ce9db","added_by":"auto","created_at":"2025-04-17 12:11:47","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":329193,"visible":true,"origin":"","legend":"\u003cp\u003e(a) A transverse section of the computed tomography (CT) abdomen and pelvis obtained at a follow-up visit is presented. This image demonstrates the presence of a Pigtail catheter in the right liver, with a small focal area of air within the hepatic parenchyma. No discernible residual drainable collection is identified at this time. (b) Revealing the sagittal section of the computed tomography (CT) abdomen and pelvis., with the consistent findings.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6450922/v1/df1376a29232cb680c9b56b6.png"},{"id":80915536,"identity":"892dece8-7861-4f12-8338-6e00945708ad","added_by":"auto","created_at":"2025-04-18 17:46:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1949467,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6450922/v1/548fc128-a5cd-45e9-b904-b027fa612cb3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Community-Acquired resistant strain of Klebsiella pneumonia in an Elderly Hispanic patient in United States: causing Klebsiella-invasive Syndrome with Primary Liver Abscess and Antibiotic Resistance","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKlebsiella pneumoniae is a common pathogen that is known to cause liver abscess formation, classically described in Asian countries; [1,2,3,4] although rare, emerging cases in Europe and the Americas are increasingly being recognized and described. [5,6,7,8,9,10] Syndromes and clinical presentations vary; pyogenic liver abscess with bacteremia has been most frequently observed in Asian countries. For example, in Taiwan, one retrospective study found 78% of pyogenic liver abscesses were due to primary K. pneumoniae infection, [3] whereas in another study conducted in New York, USA, around 41% of cases were secondary to K. pneumoniae, with most of these cases occurring in Asian individuals. [10]Typical treatment includes percutaneous drainage with a 2nd or 3rd generation cephalosporin; however, pyogenic liver abscess syndrome due to K. pneumoniae still has an overarching mortality of 10% and a 15% rate of metastatic or invasive abscess syndrome. [3]\u003c/p\u003e\n\u003cp\u003eWe present a fascinating case of a Hispanic female in her late 60s with primary pyogenic liver abscess syndrome secondary to Klebsiella pneumoniae with concurrent bacteremia complicated by a Sulfhydryl Reagent Variable Extended-Spectrum Beta-Lactamase pattern resistance. Due to initial concern for Primary Invasive Community-Acquired Liver Syndrome, which has a shockingly high mortality rate, workup discovered a unique resistance pattern in this case that is, to our knowledge, the first described occurrence of its kind, highlighting the need for the development of additional precise sensitivity panels and optimization of antibiotic therapy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA Hispanic female in her late 60s presented to the emergency department with hematuria, foul-smelling urine, headaches, dry cough, and blurry vision for three weeks. The foul-smelling urine started 3 weeks from presentation, with headaches, dry cough, blurry vision, and hematuria developing one week from presentation. She also reported polyarthralgia. Past medical history significant for pre-diabetic status; cholecystectomy was performed nine years prior to presentation. Family and social histories were unremarkable. She did endorse an allergy to Penicillin that precipitates a rash. Physical exam demonstrated joint tenderness in the left knee to palpation, otherwise negative; CRP was 328.5 mg/L and ESR 125 mm/hr, which were significantly elevated. patient was meeting systemic inflammatory response syndrome (SIRS) criteria for sepsis, prompting an infectious disease workup; urinalysis was negative other than large hematuria, and chest x-ray suggested a mild case of atypical pneumonia. [Figure. 1] A CT without contrast demonstrated a 1-cm obstructing radiolucent stone in the proximal right ureter; Urology was consulted. Incidentally, a 5-cm hepatic lesion was detected. [Figure. 2a] Her bilirubin was elevated (2.1 mg/dl) and with a hepatocellular pattern of liver injury (AST: 76 U/L, ALT: 107 IU/L); MRI with and without contrast was ordered. She was started with empiric antibiotic regimen included Cefepime (IV 2g q8h) and Azithromycin (500mg q12h). Meanwhile, she was tested for other close differentials, causing liver abscesses with serologic tests for strongyloides and Entamoeba histolytica antibodies along with stool for ova and parasite, which came negative latter in the hospital course.\u003c/p\u003e\n\u003cp\u003eOn day two, the MRI identified the hepatic lesion as a 5-cm heterogeneous, loculated abscess; [Figure. 3a \u0026amp; b] at the same time, blood cultures obtained on the day of admission were positive for Klebsiella pneumoniae, with sensitivities pending initially. Based on new-onset blurry vision, headaches, Klebsiella bacteremia, polyarthralgia, and a hepatic abscess, clinical concern for Community-Acquired Klebsiella pneumoniae Invasive Syndrome complicated by Primary Liver Abscess, was established. Interventional radiology was consulted for drain placement and fluid culture collection, infectious disease recommended adding Microgen (Next-generation sequencing and Quantitative polymerase chain reaction)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eto precisely evaluate the etiology of the hepatic abscess, ophthalmology was consulted to rule out endophthalmitis, and a transesophageal echocardiogram was ordered to rule out infective endocarditis. Metronidazole (IV 500 mg q8hr) was initiated, and Azithromycin was discontinued due to low concern for atypical pneumonia (legionella and streptococcal pneumonia urine antigen were negative). Urology placed a ureteral stent to alleviate obstructive hydronephrosis; repeated urinalysis was also negative for urinary tract infection.\u003c/p\u003e\n\u003cp\u003eThen, Ophthalmology ruled out endophthalmitis as the cause of the blurry vision, and the transesophageal echocardiogram was negative for vegetative disease, although moderate tricuspid regurgitation was identified. On day five, initial sensitivity culture results indicated Extended-Spectrum Beta-Lactamase positivity, prompting a switch to IV Cefepime 2g every 8 hour. Repeat blood cultures were negative at day five. On day seven, repeat CT demonstrated persistent abscess presence with no change in size. [Figure. 2b] This prompted a drain exchange on day nine for a larger gauge to encourage abscess drainage. At this time, Microgen test result was finalized, further indicating an unexpected finding of Sulfhydryl Reagent Variable Extended-Spectrum Beta-Lactamase positive Klebsiella pneumoniae. Finally, by day ten, Metronidazole and Cefepime were discontinued, and monotherapy with IV Ertapenem at 1g Q24H was initiated; six weeks of monotherapy with a midline placement on an outpatient basis was scheduled with a two-week follow-up appointment to remove the hepatic drain. At that time, repeat CT abdomen and pelvis revealed complete resolution of the abscess with no evidence of residual infection was achieved, [Figure. 5a \u0026amp; b] and the patient made a full recovery. The patient was followed up after two weeks. She reported feeling better and had no further issues or concerns. A CT imaging scan was repeated, which demonstrated the resolution of her previous collection. [Figure. 5a \u0026amp; b] Consequently, the drains were removed.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eKlebsiella pneumoniae is a Gram-negative, non-motile bacterium that frequently colonizes human mucosal surfaces, such as those in the gastrointestinal tract and oropharynx [11]. It can spread from these colonizing sites to other sterile tissues, causing infections such as urinary tract infections, pneumonia, and others in humans [12]. Reports have been published on the emergence and dissemination of hypervirulent (HV) or antibiotic-resistant strains of \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e [13]. The factors most associated with its virulence include lipopolysaccharides, capsules, siderophores, and fimbriae (known as pili) [12]. Among these, the capsular component, synthesized by genes from the capsular polysaccharide synthesis (cps) locus, has been extensively studied for its role in virulence [11]. Seventy different capsular serotypes have been identified in the literature, with K1 and K2 serotypes most frequently associated with liver abscesses [14, 15].\u003c/p\u003e\n\u003cp\u003eIn our patient, a mucoid strain of \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e was detected in both blood culture and abscess aspirate, though it was not further classified into subtypes. \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e has emerged as a significant cause of liver abscesses in the United States, with several reports published over the years. A review article identified 96 case reports in the United States, primarily involving patients of Asian descent. Only a few cases were reported in patients of Hispanic or Caucasian ethnicity, suggesting a possible genetic predisposition among individuals of Asian descent, which may explain the higher prevalence of \u003cem\u003eKlebsiella\u003c/em\u003e-associated liver abscesses in this population [15]. The mechanism by which \u003cem\u003eKlebsiella\u003c/em\u003e causes primary liver abscesses is not completely understood, but there is an observed association with diabetes and pre-diabetic conditions. Impaired glucose tolerance may contribute to the spread of infection by reducing neutrophil function, which is critical for breaking down the bacterial capsule [15].\u003c/p\u003e\n\u003cp\u003eOur patient had an HbA1c of 6.1 mmol/mol, placing her in the pre-diabetic range and increasing her risk of developing a primary liver abscess and bacteremia secondary to \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e. \u003cem\u003eK. pneumoniae\u003c/em\u003e is capable of infecting healthy individuals, particularly through its hypervirulent strains, and can lead to community-acquired infections such as pyogenic liver abscesses, meningitis, necrotizing fasciitis, endophthalmitis, and severe pneumonia [13].\u003c/p\u003e\n\u003cp\u003eLiver abscesses can be caused by bacterial, parasitic, or fungal pathogens. These pathogens can infect the liver through various routes, including the portal vein, biliary tree, hepatic artery, direct extension, or penetrating trauma [15]. In our case, the patient\u0026rsquo;s history of ureteral stones and diverticulosis likely contributed to the development of \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e bacteremia and subsequent primary liver abscess. Most \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e hospital-acquired infections originate from gastrointestinal tract colonization, which may extend to the urinary tract, respiratory tract, or bloodstream [16]. \u003cem\u003eKlebsiella\u003c/em\u003e can also form biofilms on medical equipment (e.g., catheters and endotracheal tubes), leading to infections [17].\u003c/p\u003e\n\u003cp\u003eA review of the literature indicates that patients with \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e-associated primary liver abscesses are typically treated with a combination of intravenous (IV) antibiotics and percutaneous liver drainage. Common antibiotic regimens include IV ceftriaxone and metronidazole, piperacillin-tazobactam, ceftriaxone alone, gatifloxacin, imipenem/levofloxacin, cefepime, ciprofloxacin/imipenem, or penicillin/gentamicin/metronidazole [15]. Our patient was initially treated with IV cefepime and metronidazole, along with percutaneous abscess drainage. However, due to the diverse resistant pattern of Klebsiella pneumoniae, it has developed resistance to beta-lactam antibiotics. [12].\u003c/p\u003e\n\u003cp\u003eA specimen from the abscess aspirate was sent for Microgen testing (next-generation sequencing), which revealed the presence of a resistant SHV beta-lactamase gene. The report also indicated resistance to fourth-generation cephalosporins. A timely decision was made to switch the patient\u0026rsquo;s antibiotic therapy to IV ertapenem, which prevented further complications. The SHV beta-lactamase gene confers resistance to various beta-lactam antibiotics. According to a review article, SHV genes are categorized into subgroups 2b, 2br, and 2be. Subgroup 2b is resistant to penicillin and early cephalosporins, subgroup 2br is resistant to clavulanic acid, and subgroup 2be is resistant to third- and fourth-generation cephalosporins [18].\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe attempted to contact the Microgen (NGS and qPCR) testing facility to further classify the SHV-resistant gene into its specific subgroup. However, this was not performed, possibly due to unavailable testing methods. This report highlights the need for further subclassification of SHV beta-lactamase-resistant genes in \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e. Early detection could help prevent complications and improve patient outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSulfhydryl Reagent Variable\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExtended-Spectrum Beta-Lactamase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest concerning the material or methods used in this study or the findings specified in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient himself for the publication of this case report and any accompanying images. A copy of this written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData-availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIM: analyzed and interpreted patient data and procedures along with the writing of the manuscript. RS: interpretation and analysis of radiological imaging with the assistance of writing the manuscript and final review. NC: procedure with final review of the manuscript. KH: final review of the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no acknowledgments to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Infectious Diseases, University of Louisville Hospital, Louisville, Kentucky, United States\u003c/p\u003e\n\u003cp\u003eImad Majeed\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDepartment of Internal Medicine, University of Louisville Hospital, Louisville, Kentucky, United States\u003c/p\u003e\n\u003cp\u003eRoarke Swank\u003c/p\u003e\n\u003cp\u003eDepartment of Internal Medicine, University of Louisville Hospital, Louisville, Kentucky, United States\u003c/p\u003e\n\u003cp\u003eNaga Chadalapaka\u003c/p\u003e\n\u003cp\u003eDepartment of infectious Diseases, University of Louisville Hospital, Louisville, Kentucky, United states\u003c/p\u003e\n\u003cp\u003eKeneth Schott Hannan\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Imad Majeed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLee SS, Chen YS, Tsai HC, Wann SR, Lin HH, Huang CK, Liu YC. Predictors of septic metastatic infection and mortality among patients with Klebsiella pneumoniae liver abscess. Clinical infectious diseases. 2008 Sep 1;47(5):642-50.\u003c/li\u003e\n\u003cli\u003eWang JH, Liu YC, Lee SS, Yen MY, Chen YS, Wang JH, Wann SR, Lin HH. Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clinical Infectious Diseases. 1998 Jun 1;26(6):1434-8.\u003c/li\u003e\n\u003cli\u003eChang FY, Chou MY. Comparison of pyogenic liver abscesses caused by Klebsiella pneumoniae and non-K. pneumoniae pathogens. Journal of the Formosan Medical Association Taiwan yi zhi. 1995 May 1;94(5):232-7.\u003c/li\u003e\n\u003cli\u003eLi J, Fu Y, Wang JY, Tu CT, Shen XZ, Li L, Jiang W. Early diagnosis and therapeutic choice of Klebsiella pneumoniae liver abscess. Frontiers of medicine in China. 2010 Sep;4:308-16.\u003c/li\u003e\n\u003cli\u003ePastagia M, Arumugam V. Klebsiella pneumoniae liver abscesses in a public hospital in Queens, New York. Travel medicine and infectious disease. 2008 Jul 1;6(4):228-33.\u003c/li\u003e\n\u003cli\u003eMcCabe R, Lambert L, Frazee B. Invasive Klebsiella pneumoniae infections, California, USA. Emerging infectious diseases. 2010 Sep;16(9):1490.\u003c/li\u003e\n\u003cli\u003eFrazee BW, Hansen S, Lambert L. Invasive infection with hypermucoviscous Klebsiella pneumoniae: multiple cases presenting to a single emergency department in the United States. Annals of emergency medicine. 2009 May 1;53(5):639-42.\u003c/li\u003e\n\u003cli\u003eSaccente M. Klebsiella pneumoniae liver abscess, endophthalmitis, and meningitis in a man with newly recognized diabetes mellitus. Clinical infectious diseases. 1999 Dec 1;29(6):1570-1.\u003c/li\u003e\n\u003cli\u003eNazir NT, Penfield JD, Hajjar V. Pyogenic liver abscess. Cleveland Clinic journal of medicine. 2010 Jul;77(7):426-7.\u003c/li\u003e\n\u003cli\u003eRahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clinical infectious diseases. 2004 Dec 1;39(11):1654-9.\u003c/li\u003e\n\u003cli\u003eKo KS. The contribution of capsule polysaccharide genes to virulence of Klebsiella pneumoniae. Virulence. 2017 Jul 4;8(5):485-6.\u003c/li\u003e\n\u003cli\u003ePaczosa MK, Mecsas J. Klebsiella pneumoniae: going on the offense with a strong defense. Microbiology and molecular biology reviews. 2016 Sep;80(3):629-61.\u003c/li\u003e\n\u003cli\u003eShon AS, Bajwa RP, Russo TA. Hypervirulent (hypermucoviscous) Klebsiella pneumoniae: a new and dangerous breed. Virulence. 2013 Feb 15;4(2):107-18.\u003c/li\u003e\n\u003cli\u003ePan YJ, Fang HC, Yang HC, Lin TL, Hsieh PF, Tsai FC, Keynan Y, Wang JT. Capsular polysaccharide synthesis regions in Klebsiella pneumoniae serotype K57 and a new capsular serotype. Journal of clinical microbiology. 2008 Jul;46(7):2231-40.\u003c/li\u003e\n\u003cli\u003eFazili T, Sharngoe C, Endy T, Kiska D, Javaid W, Polhemus M. Klebsiella pneumoniae liver abscess: an emerging disease. The American journal of the medical sciences. 2016 Mar 1;351(3):297-304.\u003c/li\u003e\n\u003cli\u003ePodschun R, Ullmann U. Klebsiella spp. as nosocomial pathogens: epidemiology, taxonomy, typing methods, and pathogenicity factors. Clinical microbiology reviews. 1998 Oct 1;11(4):589-603.\u003c/li\u003e\n\u003cli\u003eSchroll C, Barken KB, Krogfelt KA, Struve C. Role of type 1 and type 3 fimbriae in Klebsiella pneumoniae biofilm formation. BMC microbiology. 2010 Dec;10:1-0.\u003c/li\u003e\n\u003cli\u003eLiakopoulos A, Mevius D, Ceccarelli D. A review of SHV extended-spectrum \u0026beta;-lactamases: neglected yet ubiquitous. Frontiers in microbiology. 2016 Sep 5;7:1374.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Klebsiella pneumonia, Bacteremia, Liver abscess, Antibiotic resistance","lastPublishedDoi":"10.21203/rs.3.rs-6450922/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6450922/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eKlebsiella pneumoniae (K. pneumoniae) commonly causes respiratory and urinary tract infections but can also lead to community-acquired liver abscesses, primarily in Asian populations. This condition is rare in the Americas and Europe. The emergence of Sulfhydryl Reagent Variable Extended-Spectrum Beta-Lactamase (SHV ESBL) strains complicates the management of these abscesses. A Hispanic female in her late 60s presented with bloody urine after three weeks of foul odor, dry cough, headache, and blurry vision. CT abdomen and pelvis showed a 1cm right-sided ureteral calculus and a 5cm focal liver density, later confirmed as a heterogeneous loculated abscess. A nephroureteral stent was placed. Ophthalmology ruled out endophthalmitis. Blood cultures showed K. pneumoniae, while urine cultures were negative. Cefepime\u003cstrong\u003e \u003c/strong\u003ewas started based on sensitivity patterns. A CT-guided drain confirmed K. pneumoniae. qPCR and NGS revealed a positive SHV ESBL trait. Ertapenem was initiated due to the inability to specify the subtype. Persistent poor drainage prompted a drain change. Repeat imaging showed reduced abscess size. The patient was discharged on six weeks of intravenous ertapenem with weekly lab tests. This case emphasizes the importance of vigilance for community-acquired Klebsiella liver abscesses in patients with K. pneumoniae infections. Managing liver abscesses, especially those caused by SHV ESBL strains, is challenging due to the lack of specific diagnostic tools. Broad-spectrum antibiotics like carbapenems are cautiously used to prevent community resistance. Advancements in SHV ESBL studies are crucial for targeted therapy and appropriate antibiotic use.\u003c/p\u003e","manuscriptTitle":"Community-Acquired resistant strain of Klebsiella pneumonia in an Elderly Hispanic patient in United States: causing Klebsiella-invasive Syndrome with Primary Liver Abscess and Antibiotic Resistance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-17 11:55:42","doi":"10.21203/rs.3.rs-6450922/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c435d7c2-2f73-48d8-b1e3-6ebdeb072121","owner":[],"postedDate":"April 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-18T17:38:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-17 11:55:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6450922","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6450922","identity":"rs-6450922","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}