Risk stratification for metastatic infection in invasive Klebsiella pneumoniae liver abscess syndrome: a call for standardized screening protocols

Dear Editor, We read with great interest the review by Yao et al. on invasive liver abscess syndrome (ILAS) caused by hypervirulent Klebsiella pneumoniae (hvKp).1 The authors comprehensively summarized the clinical characteristics and management of this increasingly recognized condition. However, we would like to highlight an urgent clinical issue that warrants further discussion: the lack of standardized screening protocols for metastatic infection. The review noted that endophthalmitis occurs in 3–11% of ILAS patients, often resulting in devastating visual outcomes. Recent systematic reviews have reported even higher rates of metastatic complications, with ocular involvement in up to 36% of cases.2 Importantly, visual loss can occur rapidly within 24–48 h of symptom onset, yet ocular symptoms may be absent or subtle in a significant proportion of patients.1,2 This raises a critical question: should we adopt universal screening for all ILAS patients, or can we identify high-risk subgroups for targeted evaluation? Recent evidence strongly supports a risk-stratified approach. A 2025 case-control study involving 100 patients demonstrated that diabetes mellitus (OR = 2.31), smoking history (OR = 2.99) and drinking history (OR = 2.21) were independent risk factors for invasive KPLA, with poor glycemic control (high fasting blood glucose) being particularly significant.3 Notably, this study found no significant differences in bacterial virulence genes or capsular serotypes between invasive and non-invasive cases, suggesting that host factors rather than microbial characteristics drive metastatic spread.3 These findings suggest that not all patients carry equal risk, and resource-intensive universal screening may be unnecessary for low-risk individuals.