Image-guided microwave ablation has become a common treatment modality for both primary and metastatic liver tumors. The risk of serious infectious complications from this procedure is relatively low. Potential infections that can develop include hepatic abscess and cholangitis with resultant bacteremia. Previous biliary surgeries and/or manipulation may increase the risk of infectious complications. This article will describe a patient who developed acute cholangitis, two hepatic abscesses, and drug resistant bacteremia following microwave liver ablation. The challenges of diagnosing infectious complications of microwave ablation and best approach to management will also be discussed.