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ObjectiveTo compare clinical characteristics, etiology, imaging findings, treatment, and in-hospital outcomes between patients with pyogenic liver abscess with and without diabetes to support individualized clinical management.MethodsThis retrospective study included 63 patients diagnosed with pyogenic liver abscess between February 2023 and December 2025 at a tertiary hospital in Xi'an, China. The patients were divided into diabetic and non-diabetic groups. Clinical data, laboratory findings, imaging features, pathogen distribution, treatment, and in-hospital outcomes were compared. Multivariate logistic regression was performed to determine risk factors for percutaneous drainage.ResultsIn total, 63 patients were enrolled; there were no significant differences in sex, age, and inflammatory indicators between the two groups. Alanine transaminase and aspartate transaminase levels were significantly higher in the non-diabetic group, whereas albumin levels were significantly lower in the diabetic group (p = 0.04). The detection rate of Klebsiella pneumoniae was significantly higher in the diabetic group (52.2% vs. 15.0%, p = 0.001). The proportion of patients undergoing puncture and drainage was significantly higher (47.8% vs. 22.5%, p = 0.04) and the length of hospital stay was significantly longer (14.0 (9.0, 17) vs. 10 (9.0, 12.75) days, p = 0.01) in the diabetic group. There was no significant difference in the incidence of sepsis between the two groups. Multivariate regression analysis revealed that K. pneumoniae infection was an independent risk factor for the need for percutaneous drainage (odds ratio = 8.73, 95% confidence interval: 2.36-32.34, p = 0.001).ConclusionDiabetic patients with pyogenic liver abscess characteristically exhibit a predominance of K. pneumoniae infection and a longer hospital stay. Non-diabetic patients present prominent transaminitis and higher Escherichia coli infection rates. K. pneumoniae infection, rather than diabetes itself, is an independent factor associated with drainage requirement in this cohort. Tailored therapeutic strategies are recommended for this patient population based on diabetes status.