Letters to Editor
Bacteroides fragilis Causing Liver Abscess and Pyelonephritis
Dear Editor, that the isolate was susceptible to amoxicillin‑clavulanate and
meropenem but resistant to penicillin and vancomycin. Surgical
Bacteroides fragilis is an obligate anaerobe and
drainage was deferred due to the small size of the liver abscess.
Gram‑negative rod found in the oral cavity, gastrointestinal
tract, genitourinary system, and skin. [1,2] Infections with He responded to a week of parenteral followed by 3 weeks of
B. fragilis have been reported in the intra‑abdominal, oral metronidazole. A follow‑up abdominal ultrasound revealed
intestinal, hepatobiliary, skin and soft tissue, blood, lung, that the liver abscess and pyelonephritis had resolved.
urinary, gynecologic organs, brain, cerebrospinal fluid, B. fragilis is an obligate anaerobic gram‑negative bacillus that
oral, heart valve, and bone. The risk factors for B. fragilis forms part of the normal microbiota of the human colon. It is the
infection include rheumatoid arthritis, sickle cell disease, most common causative organism in anaerobic bacteremia with
cancer, and ischemic heart disease.[1] intra‑abdominal infection as the primary source.[2] Patients with
A 68‑year‑old man presented with low‑grade fever and poor pyogenic liver abscess typically present with fever, chills, and
appetite, followed by a 3‑day history of watery diarrhea. right upper quadrant abdominal pain. Pyogenic liver abscesses
The physical examination revealed no organomegaly or are frequently associated with enteric Gram‑negative bacilli
signs of peritonism. Abdominal ultrasonography revealed (Escherichia coli and Klebsiella pneumoniae), Gram‑positive
a multiloculated liver abscess in segment IV measuring cocci (streptococci, enterococci), and anaerobes (primarily
1.6 cm × 1.5 cm × 1.6 cm and features of the left pyelonephritis Bacteroides).[3] In addition, B. fragilis is a very uncommon
[Figure 1a]. B. fragilis was identified by matrix‑assisted cause of urinary tract infection. Liao et al. reported a case of
laser desorption ionization‑time‑of‑flight mass spectrometry emphysematous pyelonephritis caused by B. fragilis in which
(Bruker) from an anaerobic blood culture sample after 2 days B. fragilis was isolated from the purulent fluid following
of incubation. The isolate was susceptible to metronidazole, percutaneous nephrostomy. The patient eventually had a left
with a minimum inhibitory concentration of 0.5 μg/mL nephrectomy after failure of stone removal.[4] Prompt pathogen
[Figure 1b]. Further antimicrobial susceptibility testing showed identification, culture, and antimicrobial susceptibility are critical
in the treatment of pyogenic liver abscess. Metronidazole is the
antibiotic of choice for the treatment of B. fragilis infections,
with resistance rates ranging from 0.5% to 7.8%.[5]
Research quality and ethics statement
The authors followed applicable EQUATOR Network (https://
www.equator-network.org/) guidelines, notably the CARE
guideline, during the conduct of this report.
Declaration of patient consent
The authors certify that they have obtained all appropriate
a
patient consent forms. In the form, the patient has given his
consent for his images and other clinical information to be
reported in the journal. The patient understands that his name
and initials will not be published and due efforts will be made
to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
b
Figure 1: (a) Abdominal ultrasound showing liver abscess in segment IV Pei Shin Teo, Xin Ying Chong, Chee Yik Chang, Aishah Nazir Deen1,
and edematous left kidney. (b) After 48 h of anaerobic incubation, there Masliza Zaid
were gray, round, smooth, glistering, and nonhemolytic colonies on the Medical Department, Infectious Disease Unit, Hospital Sultanah Aminah,
blood agar. The colonies were sensitive to metronidazole disc. The gram 1
Pathology Department, Microbiology Unit, Hospital Sultanah Aminah, Johor,
stain from the anaerobic blood culture bottle showed Gram‑negative rods Malaysia
© 2024 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow 39
Letters to Editor
Address for correspondence: Dr. Chee Yik Chang,
This is an open access journal, and articles are distributed under the terms of the Creative
Medical Department, Infectious Disease Unit, Hospital Sultanah Aminah, Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Johor, Malaysia. remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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References Access this article online
Quick Response Code:
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How to cite this article: Teo PS, Chong XY, Chang CY, Deen AN, Zaid M.
4. Liao HW, Chen TH, Lin KH, Lin HH, Hsu YH, Hou CC, et al.
Bacteroides fragilis causing liver abscess and pyelonephritis. J Global Infect
Emphysematous pyelonephritis caused by Bacteroides fragilis.
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Nephrol Dial Transplant 2005;20:2575‑7.
Received: 05 November 2023 Revised: 17 November 2023
5. Ghotaslou R, Bannazadeh Baghi H, Alizadeh N, Yekani M,
Accepted: 17 November 2023 Published: 18 March 2024
Arbabi S, Memar MY. Mechanisms of Bacteroides fragilis resistance
© 2024 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
to metronidazole. Infect Genet Evol 2018;64:156‑63..
40 Journal of Global Infectious Diseases ¦ Volume 16 ¦ Issue 1 ¦ January-March 2024
