Co-evolution of resistance and virulence in Klebsiella pneumoniae liver abscess: PLA-specific mechanisms and therapeutic dilemmas

The co-evolution of resistance and virulence in Klebsiella pneumoniae poses a significant challenge in the management of pyogenic liver abscesses (PLA), particularly with the advent of carbapenem-resistant hypervirulent K. pneumoniae (CR-hv KP ). This review specifically addresses PLA to consolidate current knowledge on how key virulence factors—such as the K1/K2 capsule, hypermucoviscosity, and aerobactin—contribute to hepatic infection. It also examines the molecular mechanisms, including plasmid fusion and horizontal gene transfer, that are believed to facilitate the convergence of hypervirulence and carbapenem resistance. Additionally, the review discusses the unique clinical challenges presented by CR-hv KP in the context of PLA, including diagnostic delays, antimicrobial treatment failures, and complications in drainage. Emerging countermeasures, such as rapid molecular diagnostics and novel anti-virulence strategies, are also explored. By integrating contemporary molecular insights with the specific clinical challenges of PLA management, this review provides an updated translational perspective aimed at bridging the gap between pathogenesis and therapeutic strategies for CR-hv KP -associated infections.